Hepatology, medicine and policy最新文献

Hepatitis C virus (HCV) infection is a leading cause of liver cirrhosis and liver cancer, is curable in most people. Injecting drug use currently accounts for 80 % of new HCV infections with a known transmission route in the European Union (EU). HCV has generally received little attention from the public or policymakers in the EU, with major gaps in national-level strategies, action plans, guidelines and the evidence base. Specifically, people who inject drugs (PWID) are often excluded from treatment owing to various patient, healthcare provider and health system factors. All policymakers responsible for health services in EU countries should ensure that prevention, treatment, care and support interventions addressing HCV in PWID are developed and implemented. According to current best practice, PWID should have access to comprehensive, evidence-based multiprofessional harm reduction (especially opioid substitution therapy and clean needles and syringes) and support/care services based in the community and modified with community involvement to accommodate this hard-to-reach population. Other recommended components of care include vaccination against hepatitis B and other infections; peer support interventions; HIV testing, prevention and treatment; drug and alcohol services; psychological care as needed; and social support services. HCV testing should be performed regularly in PWID to identify infected persons and engage them in care. HCV-infected PWID should be considered for antiviral treatment (based on an individualised assessment and delivered within multidisciplinary care/support programmes) both to cure infected individuals and prevent onward transmission. Modelling data suggest that the HCV disease burden can only be cut substantially if antiviral treatment is scaled up together with prevention programmes. Measures should be taken to reduce stigma and discrimination against PWID at the provider and institutional levels. In conclusion, strategic action at the policy level is urgently needed to increase access to HCV prevention, testing and treatment among PWID, the group at highest risk of HCV infection. Such action has the potential to substantially reduce the number of infected persons, along with the disease burden and related care costs.

Background: Hepatitis B and C are major public health threats in the World Health Organization (WHO) European Region. Viral hepatitis surveillance shortcomings have resulted in many WHO Member States having insufficient data available to guide decision-making. This study describes surveillance in the region based on a quantitative sub-analysis of findings from the 2013 WHO viral hepatitis policy report and a qualitative analysis of civil society survey responses associated with these findings.

Methods: Descriptive statistics were created from information that national government focal points for viral hepatitis in 44 countries had previously reported in response to the WHO survey. Bivariate analysis was performed to compare data from within and outside of the European Union/European Economic Area (EU/EEA). Survey responses from civil society organizations in the countries of the WHO European Region were collated, and a descriptive analysis of the comments on surveillance-related questions was performed to identify key themes.

Results: The response rate for the survey of governments was 83 % among both EU/EEA countries (25/30) and non-EU/EEA countries (19/23). More than 90 % of governments reported having national surveillance systems for the acute forms of hepatitis B and hepatitis C, but less than two-thirds reported surveillance for the chronic forms of both diseases. High proportions of governments reported having central registries for the reporting of deaths (96 %) and liver cancer cases (80 %), while less than half reported regularly conducting viral hepatitis sero-surveys. All responding Member States reported having adequate laboratory capacity nationally to support hepatitis outbreak investigations and other surveillance activities. Target populations for sero-surveys most commonly included people who inject drugs (27 %), the general population (25 %), men who have sex with men (20 %) and pregnant women (20 %). Few statistically significant differences were found between EU/EEA and non-EU/EEA countries.

Conclusions: Study findings indicated a capacity for robust viral hepatitis surveillance across the WHO European Region, with most countries having important surveillance components in place, but notable weaknesses were also identified. There is an urgent need for countries throughout the region to strengthen their surveillance programs in order to maximize the population-level impact of advances in HBV and HCV prevention and treatment.

Background: The Hepatitis C virus (HCV) is very common among people who inject drugs (PWID), yet PWID in India have suboptimal access to HCV testing and treatment. This study sought to identify HCV risk factors among male PWID who utilized a free needle and syringe exchange program and to examine the predisposing, enabling, and need factors associated with utilization of HCV testing services by those PWID reporting that they had been tested.

Methods: A cross-sectional study was conducted in Imphal, Manipur and Amritsar, Punjab. These two settings have high HCV prevalence and large numbers of PWID. A team of 18 field investigators obtained data through face-to-face interviews using a structured multiple-choice questionnaire. The questionnaire was administered to 1241 of 2644 male PWID aged 15 years and above enrolled in the needle and syringe program of India's AIDS Control Program, with study participants selected through consecutive sampling. Statistical analyses included descriptive statistics and multivariate regression.

Results: Twenty-four percent of PWID in our study sample reported having been tested for HCV. Unlike PWID in Imphal, more than half of PWID in Amritsar reported unprotected sex and use of alcohol or non-injecting drugs as being among their HCV risk factors (67.1 and 77.8 %, respectively). However, opioid substitution therapy non-adherence was reported more often in Imphal than in Amritsar. Education, marital status, place of residence and duration of injecting drug use were found to significantly enable access to HCV testing while alcohol use, frequent mobility and unprotected sex were found to significantly inhibit access to HCV testing for PWID after controlling for other explanatory variables.

Conclusions: Predisposing and enabling determinants provide an area for developing effective interventions to improve HCV testing practices among PWID. HCV prevention programs that address safe injecting and sexual practices, OST adherence and frequent mobility customized for PWID by age are strongly recommended.

Background: More than 17 million people in India are chronically infected with the hepatitis B virus (HBV). Approximately one million of the 26 million children born in India annually will develop chronic HBV infection in the course of their lives. Studies have put the HBsAg prevalence rate among pregnant women in India between 0.9 % and 3.1, indicating a considerable need for public health interventions aimed at protecting their offspring from infection. The PAHAL project in Mumbai, India, conducted an HBV knowledge survey among women of childbearing age in three local slum communities preparatory to planning a comprehensive HBV education intervention targeting this population.

Methods: Female health workers approached all households in three designated slum neighborhoods: one each in the eastern suburbs (ES), western suburbs (WS) and Island City (IC). Female residents aged 18-45 were invited to participate in the study, and those who agreed to participate responded to a questionnaire that was administered in the form of an oral interview. The five sections of the questionnaire addressed demography, hepatitis B knowledge, personal risk related to hepatitis B, pregnancy and childbearing history, and the participant's most recent pregnancy. A descriptive statistical analysis was performed.

Results: Health workers submitted 6571 interview forms that were suitable for analysis (ES, 28 %; WS, 34 %; IC, 38 %). Large proportions of study participants were married (89 %), were not employed (94 %) and had completed less than 12 years of school (87 %). Only 240 (3.6 %) women answered yes when asked if they knew about hepatitis B. Among those women, there were high levels of accurate knowledge regarding some modes of hepatitis B transmission but low levels of accurate knowledge regarding other modes. Twenty-two percent of 739 women who had given birth within the previous 36 months reported that they had been tested for HBV during pregnancy. While 70 % of these women reported that their children had received three doses of hepatitis B vaccine, reported vaccination levels varied greatly across the three study areas.

Conclusions: Despite the availability of a safe HBV vaccine, which is free for newborns and infants in many parts of India, preventing mother-to-child transmission of HBV remains a major challenge. Low awareness of HBV among women of childbearing age in Mumbai-area slums indicates a need for educational interventions targeting this population.

Background: Hepatitis B is an important disease of ethnic disparity which affects Asian Americans and other minority populations disproportionately. Despite the high prevalence of hepatitis B in Asian Americans, many of them remain unscreened and untreated. A majority of the individuals chronically infected with hepatitis B virus (HBV) are not linked to care, for instance, due to a lack of culturally competent programs. There are many serious barriers preventing linkage to care (LTC), including personal, socio-cultural, and economic issues. The purpose of this study was to evaluate various barriers affecting LTC and to investigate the role and efficacy of a community-based Patient Navigator (PN) program in expediting LTC and in improving health outcomes for hepatitis B patients in a high risk population.

Methods: A total of 45 individuals chronically infected with HBV were identified through community screening events and were subsequently linked to patient navigators (PN), who then arranged for the patients to have a medical evaluation with a provider of their choice in their communities. The navigators kept detailed records of the patients' progress towards goal, and planned follow up visits for each patient. A self-report questionnaire was employed to assess patients' demographics, history of HBV infection, and barriers in accessing health care. Specifically, the levels of importance of the barriers due to language, culture, financial reasons were assessed.

Results: The study revealed that 38 of the 45 HBV infected individuals knew about their infection status from previous screening. Forty two out of 45 HBV infected individuals were linked to care within a 12 month period, demonstrating a high linkage rate. Most significant barriers identified were language and finance, followed by cultural barrier and others.

Conclusion: There are specific barriers to accessing adequate care for the patients affected by chronic hepatitis B (CHB) in Korean American community. The implementation of a PN program in conjunction with the community network of health care providers may help to overcome the barriers and facilitate LTC in hepatitis B.

Background: Hepatitis C virus (HCV) imposes a considerable disease burden in China, with at least 10 million people chronically infected. Little is known about the financial impact of the HCV epidemic, nor about the extent to which various forms of insurance are providing HCV patients with financial protection. A cross-sectional multi-site study was conducted to acquire data that will aid policy-makers and other stakeholders in developing effective strategies to address this situation.

Methods: At 29 hospitals across China, inpatients and outpatients with chronic HCV were surveyed about their insurance coverage and medical costs. Percentages, means and medians were calculated, and differences in continuous variables among multiple groups were analyzed using the Kruskal-Wallis test or Wilcoxon two-sample test.

Results: Many inpatients (N = 593) and outpatients (N = 523) reported being covered by one of three major types of government health insurance, but 13 % of inpatients and 43 % of outpatients reported having no insurance. Among inpatients, the total median cost per hospitalization per patient was 8212 Renminbi (RMB). The category of expenditure with the highest median cost per hospitalization was Western medicine, followed by lab tests and Chinese medicine. The median cost per hospitalization was far higher for patients who had hepatocellular carcinoma than for those with less severe forms of liver disease. Outpatient antiviral therapy costs ranged from a median of 377 RMB for ribavirin to a median of 37,400 RMB for pegylated interferon-alpha for up to one year of treatment.

Conclusions: For uninsured chronic HCV patients in China, inpatient and outpatient costs may be financially devastating. Research is needed on how different approaches to financing HCV treatment and care might improve health outcomes as well as achieve cost savings by enabling more people to be cured of HCV.

Background: New interferon (IFN)-free treatments for hepatitis C are more effective, safer but more expensive than current IFN-based therapies. Comparative data of these, versus current first generation protease inhibitors (PI) with regard to costs and treatment outcomes are needed. We investigated the real-world effectiveness, safety and cost per cure of 1st generation PI-based therapies in the UK.

Methods: Medical records review of patients within the HCV Research UK database. Patients had received treatment with telaprevir or boceprevir and pegylated interferon and ribavirin (PR). Data on treatment outcome, healthcare utilisation and adverse events (AEs) requiring intervention were collected and analysed overall and by subgroups. Costs of visits, tests, therapies, adverse events and hospitalisations were estimated at the patient level. Total cost per cure was calculated as total median cost divided by SVR rate.

Results: 154 patients from 35 centres were analysed. Overall median total cost per cure was £44,852 (subgroup range,: £35,492 to £107,288). Total treatment costs were accounted for by PI: 68.3 %, PR: 26.3 %, AE management: 5.4 %. Overall SVR was 62.3 % (range 25 % to 86.2 %). 36 % of patients experienced treatment-related AEs requiring intervention, 10 % required treatment-related hospitalisation.

Conclusions: This is the first UK multicentre study of outcomes and costs of PI-based HCV treatments in clinical practice. There was substantial variation in total cost per cure among patient subgroups and high rates of treatment-related discontinuations, AEs and hospitalisations. Real world safety, effectiveness and total cost per cure for the new IFN free combinations should be compared against this baseline.

Background: This article describes hepatitis B-related knowledge, attitudes and practices after completion of the Gateway to Care campaign, a citywide public health education program that targeted city residents, health care providers and individuals chronically infected with hepatitis B virus in Haimen City, China.

Methods: Pre/post questionnaires assessed hepatitis B knowledge change among health care providers and post-campaign surveys evaluated hepatitis B knowledge, attitudes and behaviors (including stigma-related beliefs and practices) among health care providers, city residents and chronically infected individuals. Focus groups were conducted to gain a more in-depth understanding of the needs of the target communities, and to identify future intervention strategies to improve hepatitis B testing and linkage to care and treatment.

Results: Results indicate high levels of hepatitis B knowledge among multiple stakeholders in Haimen City, with significant knowledge improvement among health care providers. Stigma-related beliefs and myths regarding separation of infected individuals from certain aspects of family life were common among all stakeholder groups, despite high levels of accurate knowledge about hepatitis B transmission and prevention. Self-report of hepatitis B screening was low among city residents, as was awareness of hepatitis B treatment.

Conclusions: More efforts are needed to improve awareness of HBV treatment, decrease HBV-related stigma, improve screening rates, and reduce cost of antiviral treatment. Future interventions in Haimen City should be driven by behavioral change theory, to not only improve knowledge, but to improve screening behaviors and address hepatitis B-related stigma and discrimination.

Background: Data were obtained from the third National Survey of Knowledge, Attitudes and Practices of HIV and other Sexually Transmitted Infections (STI) (PCAP-2013) and used to describe the current state of viral hepatitis (VH) knowledge and screening as well as the prevalence of viral hepatitis B (HBV) vaccination in Brazil and to assess the factors associated with testing uptake.

Methods: A probability sample survey of 12,000 individuals (50 % men) aged between 15 and 64 years was conducted between October and December of 2013. The participants completed the survey in their own homes through computer-assisted face-to-face interviews and self-interviews. We analysed data related to self-reported knowledge of VH routes and screening uptake after weighting the variables to account for unequal selection probabilities and correct for differences in sex, age and region according to 2010 census figures.

Results: The levels of correct knowledge regarding HBV and HCV transmission through unprotected sex were 33.1 and 34.3 %, respectively. The levels of correct knowledge regarding HBV and HCV transmission through tattooing/piercing were 26.4 and 24.5 %, respectively. Overall, 29 % of the respondents reported having underwent VH screening and 73.9 % reported prior HBV vaccination. VH screening was associated with the following factors: age between 25 and 49 years (adjusted male odds ratio (OR): 2.29, [95 % confidence interval (CI): 1.83-2.87]; female OR: 1.36, [95 % CI: 1.10-1.67]); age between 50 and 64 years (male OR: 1.52, [CI: 1.13-2.03]; female OR: 1.29, [CI: 1.02-1.63]); initial sexual intercourse before the age of 15 years in men (OR: 1.32, [CI: 1.10-1.57]); higher socioeconomic statuses of group A (male OR: 2.38, [CI: 1.81-3.13]; female OR: 2.10, [CI: 1.66-2.68]) and B (female OR: 1.56, [CI: 1.27-1.93]); and having ever been tested for HIV (male OR: 7.50, [CI: 5.82-8.53]; female OR: 7.13, [CI: 5.97-8.54]).

Conclusions: This study revealed low levels of knowledge regarding VH transmission and screening practices in the general Brazilian population, especially among younger individuals and those with lower socioeconomic status. Efforts to enhance awareness campaigns and expand testing sites are needed to remove barriers to testing.

Hepatology, Medicine and Policy (HMAP), a new open-access peer-reviewed journal, is making its debut at a time when the hepatitis field is seeing great progress but still has far to go. The World Health Organization and many countries have shown increasing interest in viral hepatitis in recent years, helping to foster a stronger response to this group of diseases. Meanwhile, alcohol-associated cirrhosis and alcohol-associated liver cancer continue to take a heavy toll worldwide, as does non-alcoholic fatty liver disease. The lack of a unified strategic response to viral hepatitis and other liver diseases is the impetus for launching HMAP, which will publish policy, public health and social science articles alongside clinical science articles. It will encourage submissions in diverse domains such as disease prevention and management, epidemiology, economics, health behavior, health service delivery, ethics, human rights, and the role of laws, policies and clinical guidelines in shaping health initiatives. The current attention to powerful new hepatitis C treatments presents a strategic opportunity to more comprehensively address the full constellation of biomedical and social issues relating to liver health. HMAP is committed to publishing research and policy articles that help to drive forward this broader agenda.