Barriers and Challenges and Steps Towards HBV and HCV Elimination
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Barriers and Challenges and Steps Towards HBV and HCV Elimination

Barriers and Challenges and Steps Towards HBV and HCV Elimination

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Barriers and Challenges and Steps Towards HBV and HCV Elimination Robert G Gish MD 2017 2 Suggestions on what to stop: what to start: Stop using the term physician Start using the term provider Our new team members Advanced practice nurses Update on WHO recommendations to treat hepatitis B and C and access to treatments: Making Elimination a Reality Thank you to: Dr Marc Bulterys Team lead, Global Hepatitis Programme, Department of HIV and Hepatitis; Overview of Presentation Moving towards updated guidelines The first-ever Global Strategy on Viral Hepatitis, 2016-2021 Vision: “A world where viral hepatitis transmission is halted and everyone living with viral hepatitis has access to safe, affordable and effective prevention, care and treatment services” Goal: Eliminate viral hepatitis as a major public health threat by 2030 Five strategic directions: Interventions for impact Delivering for equity Financing for sustainability Innovation for acceleration In response to this global epidemic, WHO has worked with its member states to develop the first-ever global strategy on viral hepatitis, to address and tackle this problem. This strategy was just endorsed by the WHA in May this year, with overwhelming support. The vision is world where…. Transmission is stopped and everyone has access, and the goal, very much aligned to SDG is, to eliminate viral hepatitis as a major public health problem by 2030. For the first time, we also have global targets, which are to cut new cases by 90% , and to cut mortality by 65% While these global targets are ambitious, they are important for all countries to move forward, and to measure progress as we go along. 7 6-10 million infections  (in 2015)  to 900,000 infections (by 2030) 1.34 million deaths (in 2015) to under 500,000 deaths (by 2030) This is what we are trying to achieve 8 TOPIC RECOMMENDATION APRI preferred NIT to assess for the presence of cirrhosis Who to treat Decompensated cirrhosis or cirrhosis (clinical criteria or APRI score >2), regardless of ALT levels, HBeAg, or HBV DNA. No cirrhosis but persistently abnormal ALT levels +/- ongoing HBV replication, (HBV DNA >20,000 IU/mL or HBeAg +ve). First line treatment Drugs with a high barrier to resistance (TDF or ETV). ETV in children aged 2-11 years. Treatment failure Switch to TDF if evidence of resistance to 3TC, ETV, ADF, TBV. Treatment discontinuation Never discontinue in persons with cirrhosis. If no cirrhosis, discontinuation on case-by-case basis (persistent HBeAg and/or HBsAg loss or undetectable HBV DNA) Monitoring (treatment response/toxicity) On or pre-treatment: ALT + HBV DNA (HBsAg, HBeAg + APRI pre-treatment) annually. More frequent monitoring with cirrhosis. Assessment of baseline renal function prior to treatment initiation. Monitoring for HCC Ultrasound + AFP every 6 months in persons with cirrhosis and/or family history of HCC. HBV Guideline Recommendations (2015) 9 10 Source: WHO on the basis of Center for Disease Analysis / Polaris Cascade of care for HBV infection by WHO region, 2016 4.5 million persons were on HBV treatment in 2016 (1.7 million in 2015) HBV treatment coverage increased from 8% to 16% from 2015 to 2016 Many infected persons remain undiagnosed * Measurement of progress on HBV treatment target currently limited by the absence of data on the proportion of persons eligible and the absence of a functional cure 10 Number of persons (Millions) WHO released its first HCV treatment guidelines in April 2014 Recommendations along continuum of care: Screening: Fibrosis assessment Topic Recommendation Staging Use non-invasive tests (APRI or FIB4) for assessment of liver fibrosis Treatment Considerations for prioritisation: Assessment of all adults and children with chronic HCV, including PWID for antiviral treatment Increased risk of death/fibrosis; extrahepatic manifestations; psychosocial morbidity; maximising reduction in transmission. WHO released updated HCV care and treatment guidelines in 2016 2018 UPDATE: Access to DAAs has increased but a large gap persists 1.76 million persons started HCV treatment in 2016 (1.1 million in 2015) The proportion of persons starting a new treatment increased from 7% in 2015 to 13% in 2016 Many infected persons (80%) remain undiagnosed Source: WHO on the basis of Center for Disease Analysis / Polaris Cascade of care for HCV infection, by WHO region, 2016 13 Number of persons (in millions) What has happened since release of WHO HCV 2016 guidelines? Price reductions and wider availability of generics (WHO Progress Report on Access to HCV Treatment, March 2018) New pan-genotypic DAA regimens approved: Sofosbuvir/Velpatasvir Glecaprevir/Pibrentasvir Accumulating evidence on safety and effectiveness of DAA regimens in real world (e.g., Daclatasvir/Sofosbuvir) Further guidance needed on when to start treatment and what treatment to use Whom to treat and when to start? New upcoming WHO guidance looks to move towards treating all those infected above 12 years of age (with exception of pregnant women) DAAs lead to high rates of cure (SVR) and SVR is associated with reduced all cause mortality, liver related mortality, and reduced incidence of HCC (based primarily on IFN data), SVR is associated with improvement of co-morbidities like diabetes, depression and chronic renal disease 16 Benefits Prevention of co-morbidities Public health approach to implementation Potential harms Possibility of reactivation for HBV co-infected persons Perception that harm reduction among PWID would be unnecessary 16 62% of persons living with HCV live in countries where they can access generic DAAs 23/03/18 |WHO Progress Report on Access to Hepatitis C Treatment, March 2018 Monitoring price reductions for DAAs Opportunities: Intensifying competition to reduce prices 18 Treatment of children < 12 years Among children aged less than 12 years with chronic hepatitis C infection, WHO plans to recommend: • Deferring treatment until age 12 years *Prior to approval of DAAs for children < 12 years old, exceptional treatment with interferon+ribavirin may be considered for children with genotype 2 or 3 infection, and severe liver disease. Conclusions Simplified algorithms for HBV/HCV testing and treatment, adapted to primary care, can greatly facilitate global scale-up Moving towards use of DAAs to ‘treat all’ for HCV (with the exception of pregnant women and children under age 12) Genotyping remains a barrier; thus, WHO is moving towards recommending the use of pan-genotypic DAA regimens Very dynamic price scenario for DAA regimens; registration in countries remains a barrier Equity in access to HBV/HCV testing and treatment services is a critical guiding principle. The nature and impact of stigma in patients with chronic hepatitis B: a systematic literature review J Smith-Palmer, K Bonroy, E Chan, U Sbarigia, K Cerri, R Pollock and W Valentine Introduction to stigma in hepatitis B Stigma can be defined as: “Typically a social process, experienced or anticipated, characterized by exclusion, rejection, blame or devaluation that results from experience, perception or reasonable anticipation of an adverse social judgement about a person or group. This judgement is based on an enduring feature of identity conferred by a health problem or health-related condition, and the judgement is in some way medically unwarranted.” Scambler, 2009 In many countries, people living with bloodborne diseases, such as hepatitis B virus (HBV), frequently experience disease-related stigma. For chronic diseases such as HBV stigma may be a life-long problem and can influence many areas of day-to-day life. This stigma often emanates from multiple origins, including preconceptions that the person may be an intravenous drug user (IDU) or is sexually promiscuous as well as an irrational fear of contagion, often fueled by a lack of knowledge of transmission routes of HBV. Smith-Palmer “Stigma” EASL 2018 A systematic literature review was performed to characterize hepatitis B-related stigma AIM To characterize hepatitis B-related stigma and to identify instruments that can be used to measure it. METHODS A systematic literature review was performed to identify qualitative and quantitative studies detailing hepatitis B-related stigma. Searches were designed using high level Medical Subject Heading (MeSH) terms supplemented with free text terms and performed using the PubMed, EMBASE and Cochrane Library databases. Smith-Palmer “Stigma” EASL 2018 All articles (N=1,498) All unique articles text review (n=86) Articles included in final Not stigma (n=658) Not HBV (n=321) Publication typea (n=11) Not stigma (n=7) Not HBV (n=13) Publication typea (n=41) Summary of literature review process aPublication type refers to articles that were excluded on the basis of being published in abstract form only, as well as case studies, commentaries, editorials, letters and narrative reviews Literature review identified 17 quantitative and 6 qualitative studies on hepatitis B-related stigma The majority of studies were conducted in Asia or in Asian immigrant communities in North America Most studies used custom-built surveys to assess stigma, often based on previously published surveys in HIV, but three used the HBV Stigma Instrument designed by Cotler et al. (2012) which was specifically designed to evaluate stigma in HBV Stigma was consistently reported among HBV patients, who often felt embarrassed or ashamed due to being infected with HBV, and many believed that HBV patients should avoid close contact with others Fear of contagion was frequently identified as being a key underlying cause of stigma, and this was frequently postulated to be related to lack of knowledge around transmission routes Smith-Palmer “Stigma” EASL 2018 Reference Cotler SJ, Cotler S, Xie H, Luc BJ, Layden TJ, Wong SS. Characterizing hepatitis B stigma in Chinese immigrants. J Viral Hepat. 2012 Feb;19(2):147-52 25 Study Details Custom-built online questionnaire in Asian Americana adults with chronic HBV infection Cheng et al. 2017 (US) Custom-built survey in Asian Americana adults (HBV infected and uninfected) Cotler et al. 2012 (US) Development and validation of the HBV Stigma Instrument in Chinese immigrants to the US with chronic HBV Dam et al. 2016 (US and Vietnam) HBV Stigma Instrument (Cotler et al.) in Vietnamese adults in Vietnam and the US (HBV infected and uninfected) Drazic et al. 2013 (Australia) Modified version of the Social Impact Scale in adults with chronic HBV Huang et al. 2016 (China) Custom-built survey based on Cotler et al. and Li et al. in adults with chronic HBV and uninfected controls Leng et al. 2016 (China) Custom-built survey in rural Chinese adults who had moved to Beijing (HBV infected and uninfected) Li et al. 2012 (Canada) Toronto Chinese HBV Stigma Scale in Chinesea adults (HBV infected and uninfected) aSelf-identified Huang J, et al. Liver Int. 2016;36:1595–603 Leng A, et al. Hum Vaccin Immunother. 2016;12:1164–71 Li D, et al. Can J Gastroenterol. 2012;26:597–602 26 Study Details Maxwell et al. 2012 (US) Custom-built survey based on Health Behavior Framework in four different Asian American groups (never tested for HBV) Mohamed et al. 2012 (Malaysia) Custom-built survey in chronic HBV patients Poorkaveh et al. 2012 (Iran) Stigma subscale of the HBQoL Questionnaire in chronic HBV patients Spiegel et al. 2007 (US) Development and validation of the HBQoL Questionnaire, including stigma subscale, in chronic HBV patients Van der Veen et al. 2014 (Netherlands) Custom-built survey in Turkish-Dutch immigrants (HBV infected and uninfected Wang et al. 2009 (Taiwan) Custom-built survey in students (HBV infected and uninfected) Yu et al. 2016 (China) Custom-built survey in rural adults (HBV infected and uninfected) Acosta-Gio et al. 2008 (Multinational) Custom-built survey in dental students in three Latin American countries Li et al. 2007 (China) Comparison of HCP attitudes towards HBV patients versus HIV patients based on case vignettes HBQoL, Hepatitis B Quality of Life Instrument; HBV, hepatitis B virus; HCP, healthcare professional Smith-Palmer “Stigma” EASL 2018 References Maxwell AE, et al. Asian Pac J Cancer Prev. 2012;13:1687–92 Mohamed R, et al. BMC Public Health. 2012;12:601 Poorkaveh A, et al. Arch Iran Med. 2012;15:290–7 Spiegel BM, et al. Hepatology. 2007;46:113–21 van der Veen YJ, et al. J Immigr Minor Health. 2014;16:811–21 Wang WL, et al. J Nurs Res. 2009;17:10–9 Yu L, et al. Hum Vaccin Immunother. 2016;12:70–6 Acosta-Gío AE, et al. Int Dent J. 2008;58:187–93 Li L, et al. Int J Epidemiol. 2007;36:178–84 27 Some of the most pronounced examples of hepatitis B-related stigma were reported in rural adults in China Leng A, et al. Hum Vaccin Immunother. 2016;12:1164–71 Yu L, et al. Hum Vaccin Immunother. 2016;12:70–6 Proportion of rural Chinese (or rural Chinese immigrants to urban areas) unwilling to interact with HBV carriers/patients 28 Accept gifts from HBV carrier/patient Let their children marry HBV carrier/patient Let their children play with HBV carrier/patient Have dinner with a HBV carrier/patient Hug/shake hands with a HBV carrier/patient 39.799999999999997 78.2 64.7 51.4 42.8 Yu et al. 2016 Accept gifts from HBV carrier/patient Let their children marry HBV carrier/patient Let their children play with HBV carrier/patient Have dinner with a HBV carrier/patient Hug/shake hands with a HBV carrier/patient 47.6 81.7 68.3 56.8 49.9 % of respondents unwilling to... Institutional stigma was believed to be more common in Asia than in North America Institutional stigma Stigma existing at a system-wide level (e.g. Instigated by governments, employers or insurance companies) that restricts the rights of, or marginalizes a group of people Findings Several studies in Asian populations reported that people believed that being infected with hepatitis B virus may lead to them being denied healthcare or employment opportunities Cotler SJ, et al. J Viral Hepat. 2012;19:147–52 Dam L, et al. Can J Gastroenterol Hepatol. 2016;1910292 Huang J, et al. Liver Int. 2016;36:1595–603 Smith-Palmer “Stigma” EASL 2018 Two studies examined hepatitis B-related stigma exclusively in healthcare professionals (HCPs) In one study in dental students in Latin American countries, attitudes towards people infected with hepatitis B were generally positive, but approximately 15% objected or strongly objected to treating patients infected with hepatitis B virus (Acosta-Gío et al. 2008) In a study in HCPs in China, attitudes towards patients with HBV were found to be more favorable compared with patients with HIV. For example, a significantly higher proportion of HCPs were willing to work with or socialize with people with chronic hepatitis B infection compared with people with HIV infection (Li et al. 2007) Smith-Palmer “Stigma” EASL 2018 30 Conclusions To date, published studies on HBV-related stigma have predominantly been conducted in Asian or Asian immigrant populations and data from Western Europe are lacking Stigma directed towards people infected with HBV is common in Asian countries and can negatively impact many aspects of everyday life as well as educational and employment opportunities. HBV-related stigma in other regions including North and South America and Europe is not as well characterized Despite the availability of a vaccine, fear of contagion is a key driver of stigma, which in some studies was attributed to a lack of knowledge around transmission routes Clinical consequences of stigma could potentially include an unwillingness to seek testing, which in turn could lead to a delay in treatment for those patients requiring treatment as well as a risk of onward transmission in patients remaining unaware of their HBV status Smith-Palmer “Stigma” EASL 2018 a US Veteran Patient Population Tatyana Kushner 1, David Kaplan1, 2, Marina Serper1, 2 1Division of Gastroenterology, Department of Medicine, University of Pennsylvania, Philadelphia, PA 2Corporal Michael J Crescenz VA Medical Center We performed a retrospective analysis of 125 US Veterans with chronic HBV within the 3 sites affiliated with the Philadelphia VA Medical Center (PVAMC) from 1999-2012, including academic, community, and outpatient practice environments. Patients with acute HBV were excluded (n=12). We collected demographic and clinical data. Process of care outcomes included specialist consultation, hepatitis B confirmation, liver imaging, and follow up lab testing. Predictors for appropriate and insufficient follow-up were examined. TABLE 2. Proportion of Patients who Received Appropriate Care Care Measure 36% 61 ( 49%) 25 (41%) 37 (16%) HBV serologic confirmation within 6 months within a year 4 (5%) 23 (18%) 12 (12%) Kushner AASLD 2016 FIG 2. Proportion of patients who had care measures met within a year TABLE 3. TIME TO CARE MEASURES Care Measure 3.9 (0.5, 13.7) a US Veteran Patient Population Tatyana Kushner 1, David Kaplan1, 2, Marina Serper1, 2 1Division of Gastroenterology, Department of Medicine, University of Pennsylvania, Philadelphia, PA 2Corporal Michael J Crescenz VA Medical Center 51% of patients did not receive referrals to specialty care, despite 85% with primary care follow-up Appropriate laboratory testing was often not performed during follow-up Psychiatric history and HBV care provided in the outpatient (versus inpatient) setting were associated with poor HBV follow-up Cirrhosis was predictive of poor imaging follow-up BACKGROUND Studies have demonstrated poor follow-up and adherence to AASLD guidelines in chronic hepatitis B (HBV) care. These guidelines assist providers in appropriate monitoring of HBV related laboratory parameters, imaging for HCC screening, and appropriate serologic workup. We sought to identify patient, provider and system-specific risk factors for gaps in quality of HBV care within the Veterans Health Administration. SUMMARY 1. Lok AS, McMahon BJ. Chronic hepatitis B: update 2009. Hepatology 2009; 50:661–2.3. 2. Burman BE, Mukhtar NA, Toy BC, et al. Hepatitis B management in vulnerable populations: gaps in disease monitoring and opportunities for improved care. Dig Dis Sci 2014;59:46-56. 3. Hearn B, Chasan R, Bichoupan K, et al. Low Adherence of HIV Providers to Practice Guidelines for Hepatocellular Carcinoma Screening in HIV/Hepatitis B Coinfection. Clin Infect Dis 2015. REFERENCES We performed a retrospective analysis of 125 US Veterans with chronic HBV within the 3 sites affiliated with the Philadelphia VA Medical Center (PVAMC) from 1999-2012, including academic, community, and outpatient practice environments. Patients with acute HBV were excluded (n=12). We collected demographic and clinical data. Process of care outcomes included specialist consultation, hepatitis B confirmation, liver imaging, and follow up lab testing. Predictors for appropriate and insufficient follow-up were examined. RESULTS N (%) 26 (45%) 24 (41%) 1 (1.7%) 1 (1.7% 37 (56%) 20 (30%) 2 (3%) 1 (1.7%) Age (m, SD) 6 (10%) 6 (10%) 23 (39%) 4 (6%) 6 (9%) 26 (39%) Prior history of HBV Median ALT (IQR) 33 (23, 43) 50 (27, 95) * Appropriate Care is defined as receiving liver imaging, specialty consult, and HBV confirmation within a year of presentation to the VA. **Comorbidities include CHF, diabetes, COPD, CKD, CAD, cancer METHODS TABLE 3. Characteristics associated with lack of follow-up (univariate analysis) CONCLUSIONS Outcome Characteristic No HBV Confirmation No appropriate imaging Not receiving all necessary lab tests* Outpatient Care vs. Inpatient Care (OR 1.98; p=0.127) *Necessary lab tests defined as HBV DNA, HBeAg, HBeAb tests TABLE 2. Proportion of Patients who Received Appropriate Care Care Measure 36% 61 ( 49%) 25 (41%) 37 (16%) HBV serologic confirmation within 6 months within a year 4 (5%) 23 (18%) 12 (12%) Proposed future Interventions to Improve HBV Care in US Veterans Specialist referral predicted improved adherence to HBV care. Presence of cirrhosis predicted poor follow-up- this group should be a target for future interventions Psychiatric comorbidity was associated with poor follow-up, likely as a result of a HBsAg screening program for all psychiatric hospital admissions without appropriate specialty follow-up. There were racial differences in appropriate follow-up. We identified significant gaps in HBV care. Interventions to improve care linkage are needed in the VA to improve outcomes. 64% 29% 71% 18% Prepopulated electronic medical record order sets and best practice alerts Education initiative in Psychiatry department to increase referral to Specialists of HBV+ patients Telehealth initiatives to improve access to specialty care consultation in community-based VAs The authors of this abstract have no financial disclosures. 34 35 HBsAg= 5.76% HBeAg=28.42% Xin X, et al. J Clin Virol. 2016 764,460 women of childbearing age (20-49) in 292 counties of 31 provinces of China HBsAg+ prevalence rate 6% among women of childbearing age Each year, 1 M HBsAg+ mothers give birth to babies About 1/3 of them are of high HBV DNA 50,000 newborns are infected via HBV MTCT Elimination of the Risk for Pediatric HBV Transmission To reduce vaccine failures Improve HBV Vaccine birth dose coverage to >99% Confirm all HBV vaccine doses <12 hours of birth eAg/ HBV DNA testing for HBsAg+ mothers Anti-viral prophylaxis with TDF for Mothers Confirm HBIG for infants at >99% coverage As updated from 37 Perinatal 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2002 2004 2006 2008 2010 6048 3277 3000 2763 2316 1682 1500 1350 1200 1050 826 796 876 799 818 812 4-Jan 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2002 2004 2006 2008 2010 19-May 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2002 2004 2006 2008 2010 > 19 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2002 2004 2006 2008 2010 FB 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2002 2004 2006 2008 2010 Patient Barriers to HBV Screening & Care Society Shared experiences of stigma/discrimination Immigration policies (health insurance) Proximity to doctor Access to appropriate and accessible health care systems (community clinic with language capacity) Transportation options Clinical policies of physicians/hospital (HBV screening) Interpersonal (Doctor/Patient) Limited communication Individual under-insurance Time (shift-work, lack of benefit) Low health literacy Perception of feeling well Low income Trust in physician Bracket = myths, knowledge, attitudes, beliefs, values – strong cultural belief in fate and gambling, knowing people who have died of HCC and HBV, not wanting to burden family, THIS is not all of them 40 Organizational Factors Policy endorsements from professional organizations Inclusion of HBV screening in professional clinical outcomes assessment Organizational culture/climate/attitude re: HBV testing (among physicians’ practice setting) Social Factors HBV-testing knowledge (test ordering; test interpretation) Physician-patient communication Perception of patients’ ability to afford treatment Access to/knowledge of HBV screening guidelines Ethnicity Access to educational sessions/conferences/ seminars/CMEs When a patient prompts, they are 5x more likely to be tested for HBV. When a provider prompts AND a patient is informed, they are 8x more likely to be tested for HBV. Most New Reports of HBV in the United States Are Among the Foreign Born : Test all immigrants at point of entry to the US HBsAg+ Persons Reported by Place of Birth, 1990-2005 Global Burden of HBV Disease 264 M US Born Foreign Born Year Number of cases Perinatal 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 7923 3277 3000 2763 2316 1682 1500 1350 1200 1050 826 796 876 799 818 800 4-Jan 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2945 3033 2440 1861 1672 1500 1400 1284 1219 675 471 380 158 112 135 45 19-May 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 3662 3187 2793 2535 2076 1780 1663 1669 1508 863 763 571 428 321 283 192 > 19 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 10241 8572 7690 6314 5940 5120 5004 4840 4807 3677 3877 3827 3986 3706 3066 2691 FB 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 51052 56352 45940 46407 39597 37028 43540 37592 29875 28447 37202 46979 47152 33480 43844 53376 CDC: Effectiveness of HCV Testing for Persons Born During 1945-1965 3 large primary care health systems (2012-2014) Systematic 1-time HCV test versus usual care (likely risk based or medical indication-based testing) 3 independent HCV testing trials (results available for 2) Trial 1: Patient letters; stratified multi-clinic, individually randomized (9 clinics) Trial 2: Best Practice Alert; cluster randomized (10 clusters) No prior HCV test or infection Birth-cohort HCV testing 4 times more effective in identifying persons with HCV infection compared with usual care Smith BD, et al. Hepatology. 2014;60(suppl 1):295A. Abstract 194. HCV Identified (per 1000 eligible) Trial 1 Birth cohort testing (n=2996) Usual care (n=5996) 2.7 0.3 Trial 2 Birth cohort testing (n=2996) Usual care (n=5996) 3.0 1.1 HCV Testing Results Slide: CDC: Effectiveness of HCV Testing for Persons Born During 1945-1965 Reference Smith BD, Yartel AK, Brown KA, et al. Effectiveness of hepatitis C virus (HCV) testing for persons born during 1945-1965 – summary results from three randomized controlled trials. Hepatology. 2014;60(suppl 1):295A. Abstract 194. 43 AllScripts Prompt Drexel’s “C a Difference” developed the following AllScripts alerts to help providers adhere to CDC Hepatitis C testing recommendations 1) All individuals who were born between 1945 and 1965 who have not been previously tested for HCV will have this alert in the chart: For these patients, type “hcvscreen” to order HCV antibody screening with reflex confirmatory PCR quantitative testing 44 HCV Antibody Test Volume Increased after EMR Prompt Beth Israel Deaconess Medical Center, Boston, MA, Quality Outcomes Data, 6/5/14 Boomers Boomers 40930 40958 40986 41014 41042 41070 41098 41126 41154 41182 41210 41238 41266 41294 41322 41350 41378 41406 41434 41462 41490 41518 41546 41574 41602 41630 41658 41686 41714 41742 310 281 336 324 310 295 268 312 332 397 434 414 397 437 461 493 457 496 804 1204 1294 1139 1477 1396 1247 1059 924 1052 1135 1180 Learn from HCV: Do One Thing Campaign HCV Testing and Linkage to Care Cascade n=1,301 58% Linkage to care: step down EMR EHR Quality Metrics Lessons learned from resource constrained countries and the US experience There are no HBV POC tests in the US Epidemiological and clinical questionnaires Biochemical and virological tests Part 3 Mission The mission of Project ECHO™ (Extension for Community Healthcare Outcomes) is to develop the capacity to safely and effectively treat chronic, common and complex diseases in rural and underserved areas and to monitor outcomes. Supported by NM Dept. of Health, Agency for Health Research and Quality, New Mexico Legislature, Robert Wood Johnson Foundation ECHO Summary of operational recommendations to overcome barriers Pay for HBV testing: CMS approval for payment for testing: as first step Vaccinate the world Vaccinate in the US: birth dose effect, refund “317” vaccine program Test all mothers and link to second level testing, confirm treatment in 3rd trimester for women with HBV DNA >10^5, HBV Vaccine and HBIG at >99% Invest in research, research to assist clinical/operations to test and link to care proportional to disease impact/ deaths, Department of Corrections, VA and immigrant clinics such as FQHC; Fund community screening events at cost of program Develop EMR EHR prompts, education, incentives, quality metrics, outcomes, country of birth All HBV therapies need to be Tier 1 with no coPays Start, enhance and expand ECHO models for HBV care Enhance FDA and regulatory dialogue to expedite new drug-cure approval Join forces with WHO, ICE, HBV Forum, HB Foundation, HB Task Force, HB United to drive HBV elimination Invest in advanced research on prevalence and health impact of HBV Lab testing: Provide HBV POC testing in the US, HBsAg(+) should be deemed a critical lab value HBV core antibody testing should be part of testing paradigms to decrease the use of unnecessary vaccination Use Pharmacy services/ collaborations for POC and linkage to care Acknowledgements Chair: Saeed Hamid; Co-chair: Karla Thornton; Methodologist: Roger Chou Members: Rakesh Aggarwal; Evaldo Stanislau Araújo; Anton Basenko; Davaadorj Duger; Manal El-Sayed; Charles Gore; Azumi Ishizaki; Giten Khwairakpam; Funmi Lesi; Niklas Luhmann; Constance Mukabatsinda; Francesco Negro; David R. Nelson; Ponsiano Ocama; Jürgen Rockstroh; Regina Sidjabat; Tracy Swan; Emma Thomson; Alex Thompson; Lai Wei; Stefan Wiktor WHO Steering Group: Marc Bulterys, Philippa Easterbrook, Nathan Ford, Judith van Holten, Yvan Hutin, Françoise Renaud (HIV Dept); Peter Beyer, Nicola Magrini (EMP Dept); Nick Walsh (PAHO) Other WHO staff: Andrew Ball, Rewari Bharat, Polin Chan, Tomoyuki Hayashi, Sarah Hess, Gottfried Hirnschall, Lydia Kawanguzi, Antons Mozalevskis, Oyuntungalag Namjilsuren Evidence review teams Peer reviewers Thank you to all my mentors and those who guided me to help eliminate and the eradicate HBV from the US and worldwide: John Ward Mark Thursz Stacey Trooskin, Emalie Heriaux, Rachel Ward HB Foundation, the Blocks and the team that supports HBV research HB United, Chari Cohen Echo Group, Sanjeev Arora Viral Hepaitis Alliance for Vietnam Doan Dao Cami Graham Steve Locarnini and Peter Revill CEVHAP Team