Historical epidemiology of hepatitis C virus in select countries-volume 4.

Due to the introduction of newer, more efficacious treatment options, there is a pressing need for policy makers and public health officials to develop or adapt national hepatitis C virus (HCV) control strategies to the changing epidemiological landscape. To do so, detailed, country-specific data are needed to characterize the burden of chronic HCV infection. In this study of 17 countries, a literature review of published and unpublished data on HCV prevalence, viraemia, genotype, age and gender distribution, liver transplants and diagnosis and treatment rates was conducted, and inputs were validated by expert consensus in each country. Viraemic prevalence in this study ranged from 0.2% in Hong Kong to 2.4% in Taiwan, while the largest viraemic populations were in Nigeria (2 597 000 cases) and Taiwan (569 000 cases). Diagnosis, treatment and liver transplant rates varied widely across the countries included in this analysis, as did the availability of reliable data. Addressing data gaps will be critical for the development of future strategies to manage and minimize the disease burden of hepatitis C.

Strategies to manage hepatitis C virus infection disease burden-Volume 4.

The hepatitis C virus (HCV) epidemic was forecasted through 2030 for 17 countries in Africa, Asia, Europe, Latin America and the Middle East, and interventions for achieving the Global Health Sector Strategy on viral hepatitis targets-"WHO Targets" (65% reduction in HCV-related deaths, 90% reduction in new infections and 90% of infections diagnosed by 2030) were considered. Scaling up treatment and diagnosis rates over time would be required to achieve these targets in all but one country, even with the introduction of high SVR therapies. The scenarios developed to achieve the WHO Targets in all countries studied assumed the implementation of national policies to prevent new infections and to diagnose current infections through screening.

The present and future disease burden of hepatitis C virus infections with today's treatment paradigm: Volume 4.

Factors influencing the morbidity and mortality associated with viremic hepatitis C virus (HCV) infection change over time and place, making it difficult to compare reported estimates. Models were developed for 17 countries (Bahrain, Bulgaria, Cameroon, Colombia, Croatia, Dominican Republic, Ethiopia, Ghana, Hong Kong, Jordan, Kazakhstan, Malaysia, Morocco, Nigeria, Qatar and Taiwan) to quantify and characterize the viremic population as well as forecast the changes in the infected population and the corresponding disease burden from 2015 to 2030. Model inputs were agreed upon through expert consensus, and a standardized methodology was followed to allow for comparison across countries. The viremic prevalence is expected to remain constant or decline in all but four countries (Ethiopia, Ghana, Jordan and Oman); however, HCV-related morbidity and mortality will increase in all countries except Qatar and Taiwan. In Qatar, the high-treatment rate will contribute to a reduction in total cases and HCV-related morbidity by 2030. In the remaining countries, however, the current treatment paradigm will be insufficient to achieve large reductions in HCV-related morbidity and mortality.

The present and future disease burden of hepatitis C virus infections with today's treatment paradigm - volume 3.

The total number, morbidity and mortality attributed to viraemic hepatitis C virus (HCV) infections change over time making it difficult to compare reported estimates from different years. Models were developed for 15 countries to quantify and characterize the viraemic population and forecast the changes in the infected population and the corresponding disease burden from 2014 to 2030. With the exception of Iceland, Iran, Latvia and Pakistan, the total number of viraemic HCV infections is expected to decline from 2014 to 2030, but the associated morbidity and mortality are expected to increase in all countries except for Japan and South Korea. In the latter two countries, mortality due to an ageing population will drive down prevalence, morbidity and mortality. On the other hand, both countries have already experienced a rapid increase in HCV-related mortality and morbidity. HCV-related morbidity and mortality are projected to increase between 2014 and 2030 in all other countries as result of an ageing HCV-infected population. Thus, although the total number of HCV countries is expected to decline in most countries studied, the associated disease burden is expected to increase. The current treatment paradigm is inadequate if large reductions in HCV-related morbidity and mortality are to be achieved.

Strategies to manage hepatitis C virus infection disease burden - volume 3.

The hepatitis C virus (HCV) epidemic was forecasted through 2030 for 15 countries in Europe, the Middle East and Asia, and the relative impact of two scenarios was considered: increased treatment efficacy while holding the annual number of treated patients constant and increased treatment efficacy and an increased annual number of treated patients. Increasing levels of diagnosis and treatment, in combination with improved treatment efficacy, were critical for achieving substantial reductions in disease burden. A 90% reduction in total HCV infections within 15 years is feasible in most countries studied, but it required a coordinated effort to introduce harm reduction programmes to reduce new infections, screening to identify those already infected and treatment with high cure rate therapies. This suggests that increased capacity for screening and treatment will be critical in many countries. Birth cohort screening is a helpful tool for maximizing resources. Among European countries, the majority of patients were born between 1940 and 1985. A wider range of birth cohorts was seen in the Middle East and Asia (between 1925 and 1995).

Historical epidemiology of hepatitis C virus (HCV) in select countries - volume 3.

Detailed, country-specific epidemiological data are needed to characterize the burden of chronic hepatitis C virus (HCV) infection around the world. With new treatment options available, policy makers and public health officials must reconsider national strategies for infection control. In this study of 15 countries, published and unpublished data on HCV prevalence, viraemia, genotype, age and gender distribution, liver transplants and diagnosis and treatment rates were gathered from the literature and validated by expert consensus in each country. Viraemic prevalence in this study ranged from 0.2% in Iran and Lebanon to 4.2% in Pakistan. The largest viraemic populations were in Pakistan (7 001 000 cases) and Indonesia (3 187 000 cases). Injection drug use (IDU) and a historically unsafe blood supply were major risk factors in most countries. Diagnosis, treatment and liver transplant rates varied widely between countries. However, comparison across countries was difficult as the number of cases changes over time. Access to reliable data on measures such as these is critical for the development of future strategies to manage the disease burden.

Economic burden of hepatitis C in Egypt: the future impact of highly effective therapies.

BACKGROUND: The prevalence of hepatitis C virus (HCV) infection in Egypt is the highest in the world, yet the total economic burden has not been quantified. Improved understanding of costs and the impact of treatment strategies will provide for better allocation of resources to reduce HCV disease and economic burden. AIM: A modelling approach was used to quantify the current HCV-infected population, future disease progression and associated costs in Egypt. METHODS: Direct healthcare costs were calculated from a nationally representative hospital and a disability adjusted life year (DALY) template was used with monetary value assigned to lost life years. Three scenarios were considered: (i) Historical treatment scenario: 50% SVR; 65,000 treated annually, (ii) Current treatment scenario: 90% sustained virologic response (SVR); 65,000 treated annually, (iii) Increased treatment scenario: 90% SVR; 325,000 treated annually by 2018. RESULTS: Cumulative DALYs (2015-2030) under Scenario 1 were estimated at 7.88 million and cumulative costs estimated at $89.07 billion. Annual DALYs increased 16% during 2015-2030 while annual costs more than doubled. Scenario 2 reduced cumulative DALYs and costs by 7% and 4%, respectively. Under Scenario 3, total costs declined 73% to $1047 million during 2015-2030. As compared to Scenario 1, cumulative DALYs and costs decreased 37% and 35%, respectively. CONCLUSIONS: This is the first estimate of the total economic burden of HCV in Egypt. Extraordinary measures are necessary to substantially reduce HCV disease and cost burden. With newer therapies, strategies to reduce disease burden are feasible and cost-effective.

Historical epidemiology of hepatitis C virus (HCV) in select countries - volume 2.

Chronic hepatitis C virus (HCV) infection is a leading cause of liver related morbidity and mortality. In many countries, there is a lack of comprehensive epidemiological data that are crucial in implementing disease control measures as new treatment options become available. Published literature, unpublished data and expert consensus were used to determine key parameters, including prevalence, viremia, genotype and the number of patients diagnosed and treated. In this study of 15 countries, viremic prevalence ranged from 0.13% in the Netherlands to 2.91% in Russia. The largest viremic populations were in India (8 666 000 cases) and Russia (4 162 000 cases). In most countries, males had a higher rate of infections, likely due to higher rates of injection drug use (IDU). Estimates characterizing the infected population are critical to focus screening and treatment efforts as new therapeutic options become available.

The present and future disease burden of hepatitis C virus (HCV) infections with today's treatment paradigm - volume 2.

Morbidity and mortality attributable to chronic hepatitis C virus (HCV) infection are increasing in many countries as the infected population ages. Models were developed for 15 countries to quantify and characterize the viremic population, as well as estimate the number of new infections and HCV related deaths from 2013 to 2030. Expert consensus was used to determine current treatment levels and outcomes in each country. In most countries, viremic prevalence has already peaked. In every country studied, prevalence begins to decline before 2030, when current treatment levels were held constant. In contrast, cases of advanced liver disease and liver related deaths will continue to increase through 2030 in most countries. The current treatment paradigm is inadequate if large reductions in HCV related morbidity and mortality are to be achieved.

Historical epidemiology of hepatitis C virus (HCV) in selected countries.

Chronic infection with hepatitis C virus (HCV) is a leading indicator for liver disease. New treatment options are becoming available, and there is a need to characterize the epidemiology and disease burden of HCV. Data for prevalence, viremia, genotype, diagnosis and treatment were obtained through literature searches and expert consensus for 16 countries. For some countries, data from centralized registries were used to estimate diagnosis and treatment rates. Data for the number of liver transplants and the proportion attributable to HCV were obtained from centralized databases. Viremic prevalence estimates varied widely between countries, ranging from 0.3% in Austria, England and Germany to 8.5% in Egypt. The largest viremic populations were in Egypt, with 6,358,000 cases in 2008 and Brazil with 2,106,000 cases in 2007. The age distribution of cases differed between countries. In most countries, prevalence rates were higher among males, reflecting higher rates of injection drug use. Diagnosis, treatment and transplant levels also differed considerably between countries. Reliable estimates characterizing HCV-infected populations are critical for addressing HCV-related morbidity and mortality. There is a need to quantify the burden of chronic HCV infection at the national level.

Strategies to manage hepatitis C virus (HCV) disease burden.

The number of hepatitis C virus (HCV) infections is projected to decline while those with advanced liver disease will increase. A modeling approach was used to forecast two treatment scenarios: (i) the impact of increased treatment efficacy while keeping the number of treated patients constant and (ii) increasing efficacy and treatment rate. This analysis suggests that successful diagnosis and treatment of a small proportion of patients can contribute significantly to the reduction of disease burden in the countries studied. The largest reduction in HCV-related morbidity and mortality occurs when increased treatment is combined with higher efficacy therapies, generally in combination with increased diagnosis. With a treatment rate of approximately 10%, this analysis suggests it is possible to achieve elimination of HCV (defined as a >90% decline in total infections by 2030). However, for most countries presented, this will require a 3-5 fold increase in diagnosis and/or treatment. Thus, building the public health and clinical provider capacity for improved diagnosis and treatment will be critical.

Adding aging and gender to the women's health agenda.

The complex interaction of medical, social, and economic factors that affect women's wellness as they age requires a new paradigm that bridges the gap between those who are concerned about aging issues and those concerned about women's health. In this article, we begin this endeavor by advancing three interrelated themes: (1) there is a gendered relationship between socioeconomic structures and health over time; (2) there are gender-specific implications of health care financing and policy; and (3) there are health consequences to the gendered nature of caregiving.

Is German long-term care insurance a model for the United States?

German long-term care insurance, implemented in 1995, significantly extends the coverage of care-related risks. Given the similarities of German and U.S. institutional features, the German social insurance approach has been put forward as a possible model for long-term care in the United States. Using a political economy framework, the authors conducted a policy analysis that compares the main shortfalls of long-term care (LTC) provision in the United States and Germany, examines the responses provided by LTC insurance in Germany, and relates them to broader trends and proposals for change in welfare policy in both countries. German LTC insurance includes a high degree of consumer direction and compensation and protection for informal caregivers; it supports the extension of community-based services. Its shortfalls include the continued split between health and LTC insurance. In both countries, decentralization and institutional and financial fragmentation are some of the characteristics responsible for the failure to promote egalitarian social policy and substantially expand social protection to family- and care-related risks. The German LTC program is a good model for the United States. With a social insurance approach to LTC, costs are spread across the largest possible risk pool. Major goals that can be reached with such a program include establishment of universal entitlements to LTC benefits, consumer choice, and equitability and uniformity.

What happened to long-term care in the health reform debate of 1993-1994? Lessons for the future.

During 1993 and 1994, the United States debated but did not enact major health care reform. Although the reform efforts focused on providing health coverage for the uninsured and controlling acute care costs, many proposals included substantial long-term care initiatives. President Clinton proposed creating a large home-care program for severely disabled people of all ages and all income groups, among several other initiatives. By stressing non-means-tested public programs, the president's plan was a major departure from the Medicaid-dominated financing system for long-term care. In designing the long-term care component, the Clinton administration addressed many of the basic policy choices that must be decided in all reform efforts, including whether initiatives should be limited to older people or cover people of any age, how to balance institutional and noninstitutional care, whether to rely on government programs or on the private sector, and how to control costs. Analyzing the political and intellectual history of long-term care during the health reform debate provides lessons for future reform.

Evaluation of orthostatic blood pressure testing as a discharge criterion from PACU after spinal anesthesia.

Discharge readiness from a Phase I PACU after spinal anesthesia is frequently determined by recovery of sensory/motor function. However, no data exist indicating that recovery of sensory/motor function adequately predicts hemodynamic stability after spinal anesthesia. The conservative practice of waiting until the sensory/motor effects of spinal anesthesia have completely worn off often requires patients to remain in PACU for prolonged periods of time. The purpose of this study was to determine the safety and efficacy of using orthostatic blood pressure (BP) testing as a discharge criterion from PACU after spinal anesthesia. This study used a prospective, descriptive design to measure changes in mean arterial pressure (MAP) during orthostatic BP testing at 30-minute intervals after admission to the PACU following spinal anesthesia. A convenience sample of 121 patients admitted through the Same Day Surgery (SDS) unit was used. Results show that orthostatic BP criterion was safe and effective as an alternative to sensory/motor criteria in assessing hemodynamic stability and reducing the amount of time patients spend in the PACU after spinal anesthesia. This is a U.S. government work. There are no restrictions on its use.

Pregnancy outcomes after laparoscopic myomectomy with ultrasonic energy and laparoscopic suturing of the endometrial cavity.

STUDY OBJECTIVE: To evaluate pregnancy outcomes in women with laparoscopic removal of myomas that resulted in entry into the endometrial cavity and required laparoscopic repair of the endometrial cavity. DESIGN: Retrospective chart review (Canadian Task Force classification II-2). SETTING; Private obstetrics-gynecology practice and departments of obstetrics and gynecology at two university-affiliated hospitals. PATIENTS: Seven women with symptomatic uterine leiomyomata treated by laparoscopic myomectomy, who achieved pregnancy. INTERVENTION: Laparoscopic dissection of myomas with the ultrasonic scalpel and laparoscopic suturing of the uterus with the Endo Stitch device in three layers. MEASUREMENTS AND MAIN RESULTS: Indications for laparoscopic myomectomies were excessive bleeding and significant growth of uterine myomas. The size of myomas in all patients ranged from 12 to 2 cm. Average operating time was 232.8 minutes and average blood loss was 117.8 ml. The largest number of myomas removed from a single patient was nine. All procedures were performed on an outpatient basis and no complications occurred. All women easily achieved pregnancy and four were delivered at or near term by cesarean section. One delivered vaginally at 28 weeks secondary to uncontrolled premature labor, without uterine dehiscence. Two had elective terminations at 8 weeks. CONCLUSION: Laparoscopic suturing of the endometrial cavity in three layers does not prevent future pregnancies, and pregnancies can progress to term and in some cases be delivered vaginally without dehiscence. (J Am Assoc Gynecol Laparosc 8(1):129-136, 2001)

California Collaborative Center for Substance Abuse Policy Research: a history and update.

The California Collaborative Center for Substance Abuse Policy Research is engaged in policy research, training, and information dissemination on substance abuse policy in and for the state of California. As such it is a cosponsor of the recent Therapeutic Jurisprudence conference with Haight Ashbury Free Clinics. The following recoups a presentation made by Richard B. Seymour on behalf of Center codirector Carroll Estes at that conference on the nature, history, and future priorities of the Center.

The effects of an intervention campaign to enhance seat belt use on campus.

The national health objectives for the year 2000 called for an increase in the use of safety restraints to 85% of motor vehicle occupants. An assessment on one campus indicated that only 79% of those observed were wearing seat belts. Nursing faculty and students undertook a multimodal intervention campaign to increase seat belt use in the campus community. Observed use of seat belts increased to 81% after the week-long intervention consisting of reminder banners, media coverage, permanent reminder signs, roll-over demonstrations, a presentation on the need for seat belt use, and distribution of seat belt use pledge cards. Although the increase was small, it was statistically significant and could represent considerable savings in healthcare costs if even 2% of the population could be saved from serious injury by using seat belts. In addition, the change in seat belt use represented a decline of nearly 10% in the number of nonusers.

Membrane sweeping versus dinoprostone vaginal insert in the management of pregnancies beyond 41 weeks with an unfavorable cervix.

OBJECTIVE: To determine the best method of cervical ripening to prevent postdate inductions in women with an unfavorable cervix at 41 weeks' gestation. STUDY DESIGN: Women presenting at 41 weeks' gestation with a Bishop score of < or = 4 received daily dinoprostone (Cervidil) vaginal inserts (group I) or daily membrane sweeping (group II). RESULTS: One-hundred and eighty-two women were prospectively randomized with 91 women in each arm. The women in group II, membrane sweeping, had Bishop scores significantly greater on admission for delivery (p < 0.001), had less time elapsed from admission to delivery (p = 0.018), and had fewer labor inductions at 42 weeks (p = 0.04) than the women in group I, the dinoprostone group. In addition, a greater number of women in group II were admitted in spontaneous labor (p = 0.006) than in group I. Total antenatal costs for the membrane sweeping group was $15,120 versus $59,540 for the dinoprostone group. CONCLUSION: Daily membrane sweeping was more effective than dinoprostone administration with fewer postdate inductions at one-fourth the cost.