Effectiveness and cost-effectiveness of interventions targeting harm reduction and chronic hepatitis C cascade of care in people who inject drugs: The case of France.

Direct-acting antivirals (DAAs) represent an opportunity to improve hepatitis C virus (HCV) care cascade. This combined with improved harm reduction interventions may lead to HCV elimination especially in people who inject drugs (PWID). We assessed the effectiveness/cost-effectiveness of improvements in harm reduction and chronic hepatitis C (CHC) care cascade in PWID in France. We used a dynamic model of HCV transmission and CHC natural history and evaluated the following: improved needle/syringe programmes-opioid substitution therapies, faster diagnosis/linkage to care, earlier treatment initiation, alone and in combination among active PWID (mean age = 36). Outcomes were as follows: life expectancy in discounted quality-adjusted life years (QALYs); direct lifetime discounted costs; incremental cost-effectiveness ratio (ICER); number of infections/reinfections. Under the current practice, life expectancy was 15.846 QALYs, for a mean lifetime cost of €20 762. Treatment initiation at F0 fibrosis stage alone was less effective and more costly than faster diagnosis/linkage to care combined with treatment initiation at F0, which increased life expectancy to 16.694 QALYs, decreased new infections by 37%, with a ICER = €5300/QALY. Combining these interventions with harm reduction improvements was the most effective scenario (life expectancy = 16.701 QALYs, 41% decrease in new infections) but was not cost-effective (ICER = €105 600/QALY); it became cost-effective with higher initial HCV incidence rates and lower harm reduction coverage than in our base-case scenario. This study illustrated the high effectiveness, and cost-effectiveness, of a faster diagnosis/linkage to care together with treatment from F0 with DAAs. This "Test and treat" strategy should play a central role both in improving the life expectancies of HCV-infected patients, and in reducing HCV transmission.

Thirteen-year experience with universal Staphylococcus aureus nasal decolonization prior to cardiac surgery: a quasi-experimental study.

INTRODUCTION: Sternal wound infection (SWI) after cardiac surgery is a severe complication. Among preventive measures, pre-operative decolonization of nasal carriage of Staphylococcus aureus has recently been shown to be beneficial. This quasi-experimental study assessed the effect of decolonization on the incidence of S. aureus-associated SWI based on 19 years of prospective surveillance. METHODS: Segmented negative binomial regression was used to analyse the change over time in the incidence of S. aureus mediastinitis requiring re-operation after cardiac surgery in a French university hospital between 1996 and 2014. Universal nasal decolonization with mupirocin was introduced in December 2001. The association between pre-operative nasal carriage and SWI due to S. aureus was analysed between 2006 and 2012. RESULTS: Among 17,261 patients who underwent a cardiac surgical procedure, 565 developed SWI (3.3%), which was caused by S. aureus in 181 cases (1%). The incidence of mediastinitis caused by S. aureus decreased significantly over the study period (1.43% in 1996-2001 vs 0.61% and 0.64% in 2002-2005 and 2006-2014, respectively; P<0.001). In segmented analysis, there was a significant break in 2002, corresponding to the introduction of decolonization. Despite this intervention, pre-operative nasal carriage remained a significant risk factor for S. aureus mediastinitis (adjusted odds ratio 2.2; 95% confidence interval 1.2-4.2), as were obesity, critical pre-operative status, coronary artery bypass grafting (CABG), and combined surgery with valve replacement and CABG. CONCLUSION: Universal nasal decolonization before cardiac surgery was effective in decreasing the incidence of mediastinitis caused by S. aureus. Nasal carriage of S. aureus remained a risk factor for S. aureus-associated SWI.