Thursday, February 7, 2019

Impact of Hepatitis C Virus and Insurance Coverage on Mortality

The American Journal of Managed Care February 2019
Impact of Hepatitis C Virus and Insurance Coverage on Mortality
Haley Bush, MSPH; James Paik, PhD; Pegah Golabi, MD; Leyla de Avila, BA; Carey Escheik, BS; and Zobair M. Younossi, MD, MPH

View Full-text Article Online

Takeaway Points
Hepatitis C virus (HCV) prevalence is significantly higher among patients with Medicaid compared with patients with private insurance and Medicare. 

Medicaid patients who are infected with HCV have a higher risk of all-cause mortality than HCV-positive patients with private insurance coverage. 

Policy makers should consider providing additional resources to Medicaid to cover all HCV-infected individuals.

The Medicaid population has significantly higher hepatitis C virus (HCV) prevalence and mortality rates than patients with private insurance. These data must be considered when policy makers assess providing additional support to Medicaid programs for HCV elimination.

ABSTRACT
Objectives: To assess the association of payer status and mortality in hepatitis C virus (HCV)–infected patients.

Study Design: For this retrospective observational study, we used the National Health and Nutrition Examination Survey from 2000 to 2010. Adults with complete data on medical questionnaires, HCV RNA, insurance types, and mortality follow-ups were included.

Methods: We used Cox proportional hazards models to evaluate independent associations of insurance type with mortality in HCV-infected individuals. These models were rerun in the subset of HCV-positive subjects to determine the association of insurance type with mortality. The data used in this study predated the implementation of the Affordable Care Act.

Results: Among 19,452 eligible participants, 311 (1.4%) were HCV positive. HCV-positive patients were older, were more likely to be non-Hispanic black and male, and had higher prevalence of hypertension (all P <.001). HCV-positive patients were also less likely to have private insurance and more likely to be covered by Medicaid or be uninsured relative to HCV-negative patients (P <.001). Among HCV-positive patients, after adjustment for confounders, those with Medicaid coverage had an increased risk of mortality compared with those with private insurance (hazard ratio [HR], 6.31; 95% CI, 1.22-29.94) and uninsured individuals (HR, 8.83; 95% CI, 1.56-49.99).

Conclusions: Patients who have HCV are more likely to be uninsured or covered by Medicaid. HCV-positive patients with Medicaid have an increased mortality risk compared with those with private insurance. Given the high burden of HCV infection and adverse prognosis among individuals covered by Medicaid, policy makers must prioritize funding and supporting Medicaid programs.

Source Full-text article:
Am J Manag Care. 2019;25(2): In Press

Hepatitis C cure does not improve glucose control in type 2 diabetes

Article Source: infohep
The aim of infohep.org is to develop a high-quality online resource to increase awareness of viral hepatitis, its treatment, and the needs of people living with viral hepatitis in Europe. NAM (aidsmap.com) is working with the World Hepatitis Alliance and the European Liver Patients Association (ELPA) on infohep.org.

Hepatitis C cure does not improve glucose control in type 2 diabetes
Michael Carter
Published: 07 February 2019
A successful response to HCV therapy does not result in long-term improvements in glucose metabolism for patients with type-2 diabetes, according to US research published in Liver International. 
A sustained virological response (SVR) was associated with a short-term improvement in a key marker of glucose control, but these improvements were not sustained in the longer-term and within three years glucose control was comparable between SVR patients and individuals who did not receive any HCV therapy or who had an unsuccessful treatment response. 
The investigators found the same results when they restricted their analysis to patients who had a SVR after receiving treatment with direct-acting agents (DAAs). “A number of studies have reported significant decreases in HbA1c [glycosolated haemoglobin] immediately after SVR. In contrast, a recent report found that reductions in HbA1c immediately following successful treatment were not sustained after a mean duration of 2.5 years,” write the authors. “A strength of our longitudinal analysis is that our results allow us to reconcile these apparently conflicting reports.”
Read more: http://www.infohep.org/page/3426435/
Abstract: Sustained virological response does not improve long‐term glycaemic control in patients with type 2 diabetes and chronic hepatitis C

Wednesday, February 6, 2019

China Investigates Reports of H.I.V.-Tainted Blood Plasma Treatment

Chinese Blood Plasma Feared Contaminated With HIV Tests Negative ...
TIME
A statement from the National Medical Products Administration said tests for HIV, hepatitis B and hepatitis C all turned out negative. The samples were from a …

China Investigates Reports of H.I.V.-Tainted Blood Plasma Treatment
BEIJING — Officials in Shanghai are investigating reports that a Chinese pharmaceutical company may have sold more than 12,000 units of a blood plasma product contaminated with H.I.V., potentially the latest in a series of scandals that have threatened to undermine public trust in China’s medical institutions and health care system.
In a statement on its website, the Shanghai Food and Drug Administration said Wednesday night that authorities had ordered the company, Shanghai Xinxing Medicine Company, to begin an emergency recall of the potentially tainted batch of intravenous immunoglobulin, a treatment made from pooled blood plasma that is often used to treat immune disorders, and halt its production.
Read more: https://www.nytimes.com/2019/02/06/world/asia/china-blood-plasma-treatment.html

Treat All - Barriers and facilitators of hepatitis C treatment uptake among people who inject drugs enrolled in opioid treatment programs in Baltimore

Barriers and facilitators of hepatitis C treatment uptake among people who inject drugs enrolled in opioid treatment programs in Baltimore
Oluwaseun Falade-Nwulia, Risha Irvin, Alana Merkow , Mark Sulkowski, Alexander Niculescu, Yngvild Olsen, Kenneth Stoller , David L. Thomas, Carl Latkin, Shruti H. Mehta

Links
Download full-text article
Shared On Twitter: Henry E. Chang 

Highlights
•Most PWID with HCV have not been treated despite existence of effective treatments.
•Only 20% of PWID in Baltimore opioid treatment programs (OTPs) received HCV treatment.
•Recent drug use was identified as a barrier to HCV treatment.
•Peer support and HCV treatment at OTPs were identified as facilitators to HCV treatment.

Abstract

Background
Hepatitis C virus (HCV) infection is a major public health issue among people who inject drugs (PWID) with prevalence of 50–80% in the United States. Effective, simple, oral direct acting agents (DAA) of short duration with minimal side effects have been associated with cure rates > 95%. However, HCV treatment uptake among PWID remains low. We characterized the HCV care continuum, HCV treatment knowledge, as well as barriers and facilitators to HCV treatment uptake among PWID enrolled in two opioid treatment programs (OTPs) in Baltimore, Maryland, USA.

Methods
Between July and November 2016, 124 HCV infected PWID were recruited from two opioid treatment programs in Baltimore through convenience sampling. Participants completed a 50-item questionnaire to assess HCV treatment knowledge, attitudes, and practices. Progress through the HCV care continuum was assessed based on a series of questions assessing evaluation for HCV treatment, recommendation for HCV treatment by a provider, and HCV treatment initiation. HCV status was assessed based on participant self-report.

Results
The median age was 52 years (IQR 44–58), 56% were male, the majority were African American (69%), and 19% reported HIV coinfection. Participants had been tested for HCV at their primary care provider's PCP's office (34%), drug treatment center (20%), emergency room (11%), or prison (9%), and most (60%) had been diagnosed with HCV over 5 years prior. The majority reported that HCV was a major health concern for them (91%), were aware there were new treatments for HCV (89%), and that the new treatments cure most people (69%). More than half (60%) had seen a health professional who could treat HCV, 40% had HCV therapy recommended by their HCV specialist, and 20% had started or completed treatment. In univariable analysis, PWID were significantly more likely to have been treated if they were HIV co-infected (OR 3.4 (95% CI 1.3–9.2)) or had a partner or friend concerned about their HCV (OR 3.4 (95% CI 1.2–9.7)), and were significantly less likely to have been treated if they had used any illicit drugs in the preceding 6 months (OR 0.4 (95% CI 0.2–0.99). In multivariable analysis, having a friend or partner concerned about their HCV remained significantly associated with HCV treatment (OR 5.0 (95% CI 1.4–17.7)). When questioned about what would facilitate HCV treatment, the majority (85%) reported that a friend telling them that HCV treatment had helped them and having HCV treatment provided at their opioid treatment program would make them more likely to engage in HCV treatment.

Conclusion

Despite a high prevalence of HCV among opioid treatment program patients and the availability of effective treatments, uptake remains low. We identified several key barriers and facilitators that can affect HCV treatment uptake.

2019 Hepatitis C - Testing, Treatment Options, Stages of fibrosis and Care

Caring for patients with chronic hepatitis C infection
Basic information about hepatitis C, published Jan 31, 2019 in: Nursing2019 - Ahead of Print, available in PDF format only.

Highlights
Who is at risk?
How HCV infection progresses
Extrahepatic complications of HCV infection
Testing for HCV
Stages of fibrosis
Treatment options
Removing treatment barriers
Promising future

Nursing. 2019 Jan 31. doi: 10.1097/01.NURSE.0000553271.39804.a4. [Epub ahead of print]
Caring for patients with chronic hepatitis C infection
Chaney, Amanda, DNP, APRN, FNP-BC, FAANP
Abstract:
Hepatitis C virus (HCV) infection is the most common chronic bloodborne infection in the US. This article discusses the pathophysiology of HCV infection, new treatment options, and nursing care and patient teaching for patients with chronic HCV infection.
Begin, here..….

For Patients On This Site
2019 February Hepatitis Newsletters: Finding Support 

HCV Special Conference - Worldwide HCV Epidemiology and Impact of Treatment

Website 
February 1-2, 2019 
The goal of the conference is to promote global elimination of hepatitis C infection. World leaders in the related disciplines will assemble to establish the current state of the science and public health challenges. The experts will then formulate the most effective future steps toward elimination.

Coverage 
Executive Director - Publisher, Editor, Reporter: Jules Levin

View slides and commentary from the HCV special conference over at (NATAP), here are a few presentations to get you started:

Baby Boomers; Is There a Need to Re-Focus our Efforts for Hepatitis C Screening Away from Baby Boomers? 23% HCV+ in Rural Drug Users Pennsylvania

Worldwide; HCV Epidemiology and Impact of Treatment 

What Is The Value Of HCV Treatment?
The Cost of HCV Elimination

Begin here: http://www.natap.org/2019/AASLDEASL/AASLDEASL.htm

Tuesday, February 5, 2019

Immunotherapy combinations show promise for liver cancer

Immunotherapy combinations show promise for liver cancer
Liz Highleyman

Over years or decades, chronic hepatitis B or C, heavy alcohol use, fatty liver disease or other causes of liver damage can lead to cirrhosis and HCC, the most common type of primary liver cancer. Often diagnosed at a late stage, liver cancer is hard to treat and is a leading cause of cancer deaths worldwide. HCC does not respond well to traditional chemotherapy and a majority of people do not respond to current targeted therapies or immunotherapies. Biliary tract cancer, involving the gallbladder or bile ducts, is even more difficult to treat.

Charalampos Floudas and colleagues from the US National Cancer Institute evaluated a combination of durvalumab and tremelimumab in 10 people with HCC and 12 with biliary tract cancers that could not be surgically removed or treated locally. 

Baby Boomers and the Flu

Page Last Updated: Feb 15, 2019
This post will be updated with news and current flu activity from the CDC as information is made available. Articles with a focus on liver disease, viral hepatitis, baby boomers and the flu are found further down this page.

News
Feb 13 - Earlier Tamiflu May Cut Death Risk in Some Severe Cases , observed 30% decrease in mortality with early oseltamivir among influenza A/H3N2 patients in ICU. Feb 18 - Research: 'Killer' cells raise hope of universal flu vaccine.

Latest CDC Update: Feb 15, 2018
2018-2019 Influenza Season Week 6 ending February 9, 2019

View Interactive Map


According to CDC's; Weekly U.S. Influenza Surveillance Report, this flu season has not been as severe as last year, although activity is now widespread, and at the highest levels since the start of the season. This week NBC news reported the flu season may be milder due to a better flu vaccine match; but less severe flu season doesn't underscore the very serious consequences flu can have, experts say. Watch the following video for additional information: CDC Touts Effectiveness Of This Year's Flu Vaccine.

A total of 6,868 influenza-associated hospitalizations were reported between October 1, 2018 and February 9, 2019, and a total of 34 influenza-associated pediatric deaths occurring during the 2018-2019 season have been reported.

Here is the latest updated from the CDC:
Influenza activity continues to increase in the United States. Influenza A(H1N1)pdm09, influenza A(H3N2), and influenza B viruses continue to co-circulate. Below is a summary of the key influenza indicators for the week ending February 9, 2019:
  • Viral Surveillance:The percentage of respiratory specimens testing positive for influenza viruses in clinical laboratories increased. Influenza A(H1N1)pdm09 viruses have predominated in most areas of the country, however influenza A(H3) viruses have predominated in the southeastern United States (HHS Region 4). In the most recent three weeks, influenza A(H1N1)pdm09 and influenza A(H3) viruses were reported in approximately equal numbers in HHS Regions 6 and 7.
    • Virus Characterization: The majority of influenza viruses characterized antigenically are similar to the cell-grown reference viruses representing the 2018–2019 Northern Hemisphere influenza vaccine viruses.
    • Antiviral Resistance: The vast majority of influenza viruses tested (>99%) show susceptibility to oseltamivir and peramivir. All influenza viruses tested showed susceptibility to zanamivir.
  • Influenza-like Illness Surveillance: The proportion of outpatient visits for influenza-like illness (ILI) increased to 4.8%, which is above the national baseline of 2.2%. All 10 regions reported ILI at or above their region-specific baseline level.
    • ILI State Activity Indictor Map: New York City and 26 states experienced high ILI activity; the District of Columbia, Puerto Rico and eight states experienced moderate ILI activity; 11 states experienced low ILI activity; and the U.S. Virgin Islands and five states experienced minimal ILI activity.
  • Geographic Spread of Influenza: The geographic spread of influenza in Puerto Rico and 48 states was reported as widespread; one state reported regional activity; the District of Columbia and one state reported local activity; the U.S. Virgin Islands reported sporadic activity; and Guam did not report.
  • Influenza-associated Hospitalizations A cumulative rate of 23.8 laboratory-confirmed influenza-associated hospitalizations per 100,000 population was reported. The highest hospitalization rate is among adults 65 years and older (64.1 hospitalizations per 100,000 population).
  • Pneumonia and Influenza Mortality: The proportion of deaths attributed to pneumonia and influenza (P&I) was below the system-specific epidemic threshold in the National Center for Health Statistics (NCHS) Mortality Surveillance System.
  • Influenza-associated Pediatric Deaths: Six influenza-associated pediatric deaths were reported to CDC during week 6.
Continue reading: Read : https://www.cdc.gov/flu/weekly/index.htm

Preliminary In-Season U.S. Influenza Burden Estimates
The 2018-2019 flu season is the first season CDC has reported in-season burden estimates of flu in the U.S. These in-season estimates will be updated over the course of the flu season.
CDC estimates that, from October 1, 2018 through January 26, 2019, there have been:
--10.1 million – 11.7 million flu illnesses
--4.7 million – 5.6 million flu medical visits
--118,000 – 141,000 flu hospitalizations
Read the report, here...….

Public Health Agency of Canada:
The most up-to-date influenza information from Canada is available at http://www.phac-aspc.gc.ca/fluwatch
British Columbia Influenza Surveillance Bulletin Influenza
Influenza activity remains elevated in BC and is dominated by the H1N1 strain. 
Joint ECDC - WHO/Europe Weekly Flu Update: https://flunewseurope.org/Severity

News

Video:
This flu season should serve as a wake-up call – we need to redouble our efforts to prevent and treat the flu
Seasonal outbreaks of the flu cause thousands of deaths even in a good year, and the last flu season, 2017-2018, was a terrible one. It killed 80,000 Americans and sent 900,000 to the hospital, making it the worst influenza season in decades.


Baby Boomers and the Flu 
Did you know that you are more susceptible to flu-related complications if you're over 65, living with chronic liver disease, or viral hepatitis? Yep, I knew it too. 

Currently information on this blog is aimed at people living with or treating hepatitis C, for the most part that is the baby boomer generation; born between 1946 to1964. 

Speaking of baby boomers, if you haven't read the CDC's eye- opening report on last years flu season, it was reported 80,000 flu-related deaths occurred in the US, the highest in 40 years. The death rate among young baby boomers, aged 50 to 64 were shocking as well; 
"Death rates were highest in the over-65 age group, which is typical, but the second most affected group comprised those aged 50 to 64 years old; normally, the second highest death rates occur in children, from birth through age 4 years. The ferociousness of the flu season overall, combined with above-average impacts on younger baby boomers, made 2017-2018 one for the record books."
Read the article: Flu Season 2017-2018: A Look at What Happened and What's to Come, CDC report, here. Or read this more recent article, updated Oct 19, 2018: 80,000 Americans died of the flu last winter.That’s more than the number killed in traffic collisions, from gun violence, or from opioid overdoses.

Liver Disease & The Flu
As we age our immune system is less effective in fighting infections, and new infections can have a severe impact on the liver. This can be especially serious for liver transplant recipients and people who have cirrhosis. Flu-related complications could develop into bronchitis or pneumonia, which in rare cases can also be fatal.

Even though the flu vaccine won’t keep everyone from getting sick, it helps prevent serious flu complications. For instance people over 65 who were vaccinated had a lower rate of flu-related death, according to a 2017 study, found on the CDC's website.
"Flu vaccination reduced deaths, intensive care unit (ICU) admissions, ICU length of stay, and overall duration of hospitalization among hospitalized flu patients; with the greatest benefits being observed among people 65 years of age and older."
October - In The News
October 29, 2018
Getting Flu Vaccine One Year Doesn't Reduce Vaccine Effectiveness the Next Year
By Amy Orciari Herman
Edited by Susan Sadoughi, MD, and André Sofair, MD, MPH
Getting the flu vaccine every year doesn't reduce its effectiveness — and might even boost its performance — suggests a study in JAMA Network Open.

Researchers examined the vaccination status of nearly 3400 children who presented with acute febrile respiratory illness during one of three successive flu seasons between 2013 and 2016. About one-fourth had flu confirmed on reverse-transcription polymerase chain reaction testing; the rest were considered negative for flu.

The researchers found that while vaccine effectiveness varied by vaccine type (e.g., live attenuated influenza vaccine [LAIV) or inactivated influenza vaccine) and flu virus strain, past-season vaccination did not reduce vaccine effectiveness. In fact, in some cases — for example, the effectiveness of LAIV against influenza A(H3N2) — previous vaccination appeared to improve the vaccine's effectiveness.

Of note, residual protection from past-season flu vaccine alone was observed only for influenza B.
A commentator writes, "The results thus suggest additional support for the current Advisory Committee on Immunization Practices' recommendation that children be vaccinated annually against influenza."
LINK(S):
JAMA Network Open article (Free)
JAMA Network Open commentary (Free)
Background: Physician's First Watch coverage of American Academy of Pediatrics recommendation of inactivated flu vaccine over LAIV (Free)

Oct 28, 2018
New Flu Drug Offers Convenience, Fast Activity, and a Novel Mechanism — at a Price
Last week, the FDA approved a new drug for treatment of influenza, baloxavir marboxil (Xofluza).
The drug is indicated for treatment of symptomatic influenza in patients 12 years of age or older. As with existing treatments, it should be started within 48 hours of symptom onset....

Oct 24, 2018
"I figured [the flu] was something that's dangerous to the elderly and the young, not somebody who is healthy and in their 30s," says Hinderliter, who is 39 and the director of government affairs at the St. Louis Realtors association
"Turns out, I was wrong," he says
Read the article, here.....

Should I or Shouldn't?
September 27, 2018
"People say they never had the flu until they got the shot. That argument doesn’t hold water. Either you got your shot too late, you got a strain of the flu that isn’t covered by the vaccine, or you had a one-day immune response which may make you feel like crap for the day, but isn’t anywhere like having the flu. If you are over 65, high dose flu shots are recommended, and some people feel a bit low and fluish the next day. This is not the flu – it is an immune system reaction"
Read the article: The Flu Shot Debate, written by HCV advocate Lucinda Porter.

CDC Information
People 65 years and older should get a flu shot and not a nasal spray vaccine.
They can get any flu vaccine approved for use in that age group with no preference for any one vaccine over another. There are regular flu shots that are approved for use in people 65 and older and there also are two vaccines designed specifically for people 65 and older:
High Dose Flu Vaccine:
The “high dose vaccine” contains 4 times the amount of antigen as a regular flu shot. It is associated with a stronger immune response following vaccination (higher antibody production). Results from a clinical trial of more than 30,000 participants showed that adults 65 years and older who received the high dose vaccine had 24% fewer influenza infections as compared to those who received the standard dose flu vaccine. The high dose vaccine has been approved for use in the United States since 2009.
Learn more about high dose flu vaccine here.

Adjuvanted Flu Vaccine:
The adjuvanted flu vaccine, Fluad, is made with MF59 adjuvant an additive that creates a stronger immune response to vaccination. In a Canadian observational study of 282 people aged 65 years and older conducted during the 2011-12 season, Fluad was 63% more effective than regular-dose unadjuvanted flu shots. There are no randomized studies comparing Fluad with Fluzone High-Dose. This vaccine was available for the first time in the United States during the 2016-2017 season. Learn more about adjuvanted flu vaccine here.

For Adults with LIVER DISEASE: Important information about a dangerous infection
If you have chronic liver disease, you are more likely to have serious complications if you get pneumococcal disease

Get pneumococcal vaccines 
People who are 65 years of age and older should also be up to date with pneumococcal vaccination to protect against pneumococcal disease, such as pneumonia, meningitis, and bloodstream infections. Talk to your doctor to find out which pneumococcal vaccines are recommended for you. Pneumococcal pneumonia is an example of a serious flu-related complication that can cause death. 

You can get the pneumococcal vaccine your provider recommends when you get the flu vaccine.

CDC - Got Questions?
Flu vaccines recommended this season.

Detailed flu and flu vaccine information specific to the current flu season

If you have HIV, you are at high risk of serious influenza-related complications and should get an injectable influenza vaccine (a flu shot).

Recommended Reading:
Flu and Colds: In Depth
What do we know about the effectiveness of complementary approaches for flu and colds?

Is It A Nasty Cold Or The Flu?
So, if you do have the flu, it's important to consult with your health care provider about treatment. And distinguishing between a cold and flu may be easier than you think, Ejnes says.

Stay healthy!
Tina