Physician perspectives on the management of viral hepatitis and hepatocellular carcinoma in Myanmar.

BACKGROUND: In Myanmar, over five million people are infected with hepatitis B virus (HBV) and hepatitis C virus (HCV). Hepatitis has been a recent focus with the development of a National Strategic Plan on Hepatitis and plans to subsidize HCV treatment. METHODS: During a two-day national liver disease symposium covering HCV, HBV, hepatocellular (HCC), and end-stage liver disease (ESLD), physician surveys were administered using the automated response system (ARS) to assess physician knowledge, perceptions of barriers to screening and treatment, and proposed solutions. Multivariate logistic regression was used to estimate odds ratio (OR) relating demography and practice factors with higher provider knowledge and improvement. RESULTS: One hundred two physicians attending from various specialty areas (31.0% specializing in gastroenterology/hepatology and/or infectious disease) were of mixed gender (46.8% male), were younger than or equal to 40 years old (51.1% 20 to 40 years), had less experience (61.6% with ≤10 years of medical practice), were from the metropolitan area of Yangon (72.1%), and saw <10 liver disease patients per week (74.3%). The majority of physicians were not comfortable with treating or managing patients with liver disease. The post-test scores demonstrated an improvement in liver disease knowledge (9.0% ± 27.0) compared to the baseline pre-test scores; no variables were associated with significant improvement in hepatitis knowledge. Physicians identified the cost of diagnostic blood tests and treatment as the most significant barrier to treatment. Top solutions proposed were universal screening policies (46%), removal of financial barriers for treatment (29%), patient education (14%) and provider education (11%). CONCLUSIONS: Physician knowledge improved after this symposium, and many other needs were revealed by the physician input on barriers to care and their solutions. These survey results are important in guiding the next steps to improve liver disease management and future medical education efforts in Myanmar.

A Survey of Texas HIV, Sexually Transmitted Disease, Tuberculosis, and Viral Hepatitis Providers' Billing and Reimbursement Capabilities.

The Affordable Care Act presents financial challenges and opportunities for publicly funded service providers. We assessed billing practices and anticipated barriers to third-party billing among organizations in Texas that provide publicly funded HIV, sexually transmitted diseases, tuberculosis, and viral hepatitis services. One third to one half of the organizations did not bill for medical services. The most common barrier to third-party billing was lack of staff knowledge about billing and coding. Future research must evaluate options for organizations and communities to maintain access to infectious disease services for vulnerable populations.

A medical cost estimation with fuzzy neural network of acute hepatitis patients in emergency room.

Taiwan is an area where chronic hepatitis is endemic. Liver cancer is so common that it has been ranked first among cancer mortality rates since the early 1980s in Taiwan. Besides, liver cirrhosis and chronic liver diseases are the sixth or seventh in the causes of death. Therefore, as shown by the active research on hepatitis, it is not only a health threat, but also a huge medical cost for the government. The estimated total number of hepatitis B carriers in the general population aged more than 20 years old is 3,067,307. Thus, a case record review was conducted from all patients with diagnosis of acute hepatitis admitted to the Emergency Department (ED) of a well-known teaching-oriented hospital in Taipei. The cost of medical resource utilization is defined as the total medical fee. In this study, a fuzzy neural network is employed to develop the cost forecasting model. A total of 110 patients met the inclusion criteria. The computational results indicate that the FNN model can provide more accurate forecasts than the support vector regression (SVR) or artificial neural network (ANN). In addition, unlike SVR and ANN, FNN can also provide fuzzy IF-THEN rules for interpretation.

Reducing the neglected burden of viral hepatitis in Africa: strategies for a global approach.

The burden of liver disease may dramatically increase in the near future in Africa, where screening and access to care and treatment are hampered by inadequate disease surveillance, lack of high-quality tools to assess chronic liver disease, and underestimated needs for human and financial resources. Chronic hepatitis may be considered as silent and neglected killer, fuelled by many years of global inertia from stakeholders and policy makers alike. However, the global battle against viral hepatitis is facing a new era owing to the advent of highly effective drugs, innovative tools for screening and clinical follow-up, and recent signs that governments, advocacy groups and global health organizations are mobilizing to advocate universal access-to-treatment. This review details the barriers to prevention, screening and treatment of viral hepatitis on the African continent, focuses on the urgent need for operational and research programmes, and suggests integrated ways to tackle the global epidemic.

Forgotten, not neglected: viral hepatitis in resource-limited settings, recall for action.

In 2010, the World Health Assembly adopted a resolution calling for interventions for the prevention and control of chronic viral hepatitis. These infectious diseases mostly affect resource-limited countries accounting for 80% of the world's population and facing numerous obstacles to contain the epidemic. At a time when morbidity and mortality of chronic liver disease have been considerably improved in wealthy countries by new innovative strategies and new potent antiviral drugs, it is now urgent to recall for concrete actions from stakeholders of global health policy to reduce the burden in resource-limited countries.

Costs of a public health model to increase receipt of hepatitis-related services for persons with mental illness.

OBJECTIVE: This study examined the costs and impact on receipt of hepatitis and HIV testing and hepatitis immunization services of a public health intervention model that was designed for use by persons with serious mental illness and co-occurring substance use disorders. METHODS: Between 2006 and 2008, a random sample of 202 nonelderly, predominantly African-American males with a psychotic or major depressive disorder and a co-occurring substance use disorder was recruited at four community mental health outpatient programs in a large metropolitan area. Participants were randomly assigned at each site to enhanced treatment as usual (N=97), including education about blood-borne diseases and referrals for testing and vaccinations, or to an experimental intervention (N=105) that provided on-site infectious disease education, screening of risk level, pretest counseling, testing for HIV and hepatitis B and C, vaccination for hepatitis A and B, and personalized risk-reduction counseling. The authors compared the two study groups to assess the average costs of improving hepatitis and HIV testing and hepatitis A and B vaccination in this population. RESULTS: The average cost per participant was $423 for the intervention and $24 for the comparison condition (t=52.7, df=201, p<.001). The costs per additional person tested was $706 for hepatitis C, $776 for hepatitis B, and $3,630 for HIV, and the cost per additional person vaccinated for hepatitis was $561. CONCLUSIONS: Delivery of hepatitis and HIV public health services to persons with serious mental illness in outpatient mental health settings can be as cost-effective as similar interventions for other at-risk populations.

Financial stress is associated with reduced treatment adherence in HIV-infected adults in a resource-rich setting.

OBJECTIVES: Financial stress has been identified as a barrier to antiretroviral adherence, but only in resource- limited settings. Almost half of HIV-infected Australian adults earn no regular income and, despite highly subsidised antiretroviral therapy and universal health care, 3% of HIV-infected Australians cease antiretroviral therapy each year. We studied the relationship between financial stress and treatment adherence in a resource-rich setting. METHODS: Out-patients attending the HIV clinic at St Vincent's Hospital between November 2010 and May 2011 were invited to complete an anonymous survey including questions relating to costs and adherence. RESULTS: Of 335 HIV-infected patients (95.8% male; mean age 52 years; hepatitis coinfection 9.2%), 65 patients (19.6%) stated that it was difficult or very difficult to meet pharmacy dispensing costs, 49 (14.6%) reported that they had delayed purchasing medication because of pharmacy costs, and 30 (9.0%) reported that they had ceased medication because of pharmacy costs. Of the 65 patients with difficulties meeting pharmacy costs, 19 (29.2%) had ceased medication vs. 11 (4.1%) of the remaining 270 patients (P < 0.0001). In addition, 19 patients (5.7%) also stated that it was difficult or very difficult to meet travel costs to the clinic. Treatment cessation and interruption were both independently associated with difficulty meeting both pharmacy and clinic travel costs. Only 4.9% had been asked if they were having difficulty paying for medication. CONCLUSIONS: These are the first data to show that pharmacy dispensing and clinic travel costs may affect treatment adherence in a resource-rich setting. Patients should be asked if financial stress is limiting their treatment adherence.

Tratamento da infecção pelo vírus da hepatite C em candidatos a transplante renal submetidos a diálise: impacto orçamentário no SUS / Hepatitis C treatment in patients on dialysis awaiting renal transplantation: a budget impact analysis

Trata-se de uma análise de impacto orçamentário derivada dos resultados do estudo "Custo-efetividade do tratamento da infecção pelo vírus da hepatite C em candidatos a transplante renal submetidos a diálise". Teve como objetivo estimar o impacto orçamentário da ampliação da oferta do tratamento da infecção pelo vírus da hepatite C (VHC) para candidatos a transplante renal. Para tal, foi construído um modelo de Markov, a fim de estimar o custo médio do tratamento de diferentes proporções da população-alvo. Foram estimados os casos prevalentes e incidentes da infecção na população em diálise, candidata a transplante renal, em um horizonte de tempo de dez anos. Com base nestas estimativas, foi calculado o valor a ser despendido pelo SUS para tratar a população-alvo em três cenários diferenciados, caracterizados pela proporção da população submetida ao tratamento. Os valores encontrados foram comparados com o gasto do sistema para garantia de terapias de substituição renal no período de um ano, identificando-se que o custo do tratamento de toda a população candidata a transplante, infectada pelo VHC, corresponde a 0,3 por cento do valor despendido com TRS pelo SUS.

This is an analyses of the budget impact derived from the cost-effectiveness study on the hepatitis C treatment in candidates for renal transplantation under dialysis. It aims to estimate the budget impact of an offer of hepatitis C treatment for all candidates for renal transplantation. A Markov model was developed to estimate the mean cost for treatment of distinct proportions of the target population. The prevalence and incidence of hepatitis C in the candidates for renal transplantation in the dialysis population was also estimated in a horizon of ten years. Based on these estimative, we calculate the amount needed for treatment of this population in three distinct scenarios characterized by a proportion of the population under treatment. The values were compared with the expense of the system to guarantee renal replacement therapies in one year, identifying the cost of treatment of all candidates for transplant, infected with HCV, corresponding to 0.3 percent of the amount spent with renal transplantation within the SUS.

Viral hepatitis in Hawai'i--differing perspectives.

This publication contains information from a conference titled "Individual Perspectives on the Silent Epidemic of Viral Hepatitis in Hawai'i" held in October of 2007 with updates and additional contributions from annual conferences in 2008 and 2009. These conferences were sponsored by the Hepatitis Support Network of Hawai'i and held in Honolulu, Hawai'i at the Queen's Conference Center. The primary objectives of the conferences have been to heighten awareness of viral hepatitis in Hawai'i and to bring together health care professionals to learn about these infections and to help them respond to the challenges they bring to the people of Hawai'i. The initial conference was oriented to present the unique and individual perspectives of patients, physicians, and other healthcare providers specific to the complex issues of hepatitis in an effort to help them understand their role in the context of others and to develop a team approach in responding to this epidemic.

[The viral hepatitis and its economic significance and prevention].

The reference of only part of diseases having contagious nature to the infectious pathology is closely related to the tradition of considering the infections as highly contagious diseases inclined to epidemic propagation. The data is presented related to the morbidity of viral hepatitis among the population of the City of Krasnodar. The corresponding economic losses and the achievements of medical preventive activities considering the social economic and other characteristics of the specific socium are considered.

Health risks of enteric viral infections in children.

Children are at a greater risk of infections from serious enteric viral illness than adults for a number of reasons. Most important is the immune system, which is needed to control the infection processes. This difference can lead to more serious infections than in adults, who have fully developed immune systems. There are a number of significant physiological and behavioral differences between adults and children that place children at a greater risk of exposure and a greater risk of serious infection from enteric viruses. Although most enteric viruses cause mild or asymptomatic infections, they can cause a wide range of serious and life-threatening illnesses in children. The peak incidence of most enteric viral illnesses is in children <2yr of age, although all age groups of children are affected. Most of these infections are more serious and result in higher mortality in children than adults. The fetus is also affected by enterovirus and infectious hepatitis resulting in significant risk of fetal death or serious illness. In addition to the poliovirus vaccine, the only vaccine available is for hepatitis A virus (HAV). A vaccine for rotavirus has currently been withdrawn, pending review because of potential adverse effects in infants. No specific treatment is available for the other enteric viruses. Enteric viral infections are very common in childhood. Most children are infected with rotavirus during the first 2yr of life. The incidence of enteroviruses and the viral enteric viruses ranges from 10% to 40% in children and is largely dependent on age. On average, half or more of the infections are asymptomatic. The incidence of hepatitis A virus is much lower than the enteric diarrheal viruses. There is no current evidence for hepatitis E virus (HEV) acquisition in children in the U.S. Enteric viral diseases have a major impact on direct and indirect health care costs (i.e., lost wages) and amount to several billion dollars a year in the U.S. Total direct and indirect costs for nonhospitalized cases may run from $88/case for Norwalk virus to $1,193/case for enterovirus aseptic meningitis. Direct costs of hospitalization ran from $887/case for Norwalk virus to $86,899/case for hepatitis A. These costs are based on 1997-1999 data. Generally, attack rates during drinking water outbreaks are greater for children than adults. The exception appears to be hepatitis E virus where young adults are more affected. However, pregnant women suffer a high mortality, resulting in concurrent fetal death. Also, secondary attack rates are much higher among children, probably because of fewer sanitary habits among this age group. Overall, waterborne outbreaks of viral disease have a greater impact among children than adults. To better quantify the impact on children, the literature hould be further reviewed for case studies of waterborne outbreaks where data are available on the resulting illness by age group. The EPA and/or Centers for Disease Control should attempt to collect these data as future outbreaks are documented.

Epidemiology and economic burden of viral hepatitis: an observational population based study.

OBJECTIVE: To describe the epidemiology and estimate the health resource use of patients with viral hepatitis in Tayside, Scotland, using record linkage techniques. DESIGN: A retrospective observational study. SETTING: Liver disease database, Tayside, Scotland. PATIENTS: All subjects resident in Tayside in the study period 1989-1999 and registered on the Epidemiology of Liver Disease in Tayside (ELDIT) database. MAIN OUTCOME MEASURES: Incidence and prevalence of known viral hepatitis in Tayside, survival of subjects diagnosed with viral hepatitis, and the health resource use with respect to hospital admissions compared with the general population. RESULTS: There were 4992 patients identified with viral hepatitis in the study period 1989-1999; 86 were IgM positive anti-hepatitis A, 187 patients were hepatitis B surface antigen (HBsAg) positive, and 469 were anti-hepatitis C (HCV) positive. HCV and HBsAg seropositive patients were more likely to be hospitalised and stay in hospital longer, less likely to survive after six years, and used more drugs of potential abuse than the general population. There was an increase in cost per admission and per patient as a consequence of liver disease. CONCLUSIONS: A record linkage population based study of viral hepatitis allows outcomes to be identified and costed. Those at risk of viral hepatitis infection in the Tayside population should be informed about the future implication to their health and costs to society. The health service should investigate the cost effectiveness of vaccination and opportunity costs to the health service of viral hepatitis taking into consideration the increasing incidence and prevalence of disease.

Chronic viral hepatitis: liver biopsy, yes or no?

LB increases costs and has--although minimal--potential risks; however, LB is: a) the gold standard to get to know lesion severity (grade and stage); b) the only method for the diagnosis of an F3 stage, which progresses to liver cirrhosis in approximately 10 years; c) the only method for the certain diagnosis of compensated liver cirrhosis, which requires early diagnosis programs for oesophageal varices and hepatocarcinoma; and d) the only method for the certain diagnosis of lesions predicting a good therapeutic response. On all these grounds--save for exceptions (contraindications, clinical and/or ultrasonographic cirrhosis)--liver biopsy should be carried out in the initial study of all patients. In non-responders to anti-viral therapy liver biopsy should be repeated once or twice with 5-10-year intervals to ascertain fibrosis growth rate and, according to this, plan a most appropriate follow-up. Assuming hepatitis progresses rapidly in all HIV co-infected patients, anti-viral therapy could be administered with no previous LB; such biopsy would be performed in non-responders to decide their course of therapy.