Multidisciplinary managed care networks-Life-saving interventions for hepatitis C patients.

Successful hepatitis C virus (HCV) therapy depends on effective pathways of care. Over two decades, we have developed four sequential models of care latterly using a multidisciplinary managed care network to improve HCV testing, care and treatment. This was a cohort study to evaluate the effectiveness of care pathways, carried out using all HCV antibody-positive individuals tested in a geographical region between 1994 and 2014. The study involved 3122 HCV-positive patients. They were divided into four subgroups representing different care pathways defined by their date of HCV antibody diagnosis. The number who accessed treatment services within 1 year of diagnosis increased from 77 of 292 (26.3%) to 521 of 821 (72.9%). The rate of treatment starts within 1 year of diagnosis increased from 6 of 292 (2.0%) to 133 of 821 (16.2%), and the sustained viral response rate improved from 61.6% to 77.4%. All-cause mortality decreased from 232 of 688 (33.7%) in subgroup A to 55 of 1207 (4.5%) in subgroup D, and multivariate analysis showed that pathway type was an independent predictor of mortality irrespective of age, sex, SVR status or HIV co-infection with pathway in D having an odds ratio of 0.53(0.40-0.77; P<.001) compared to pathway in A. At study end, 78% (3122) of an estimated 4000 HCV positive had been diagnosed. In total, 97.5% of HCV caseload was referred to specialist services and 89% attended for assessment. The introduction of a managed care network increased access to care and reduced all-cause mortality.

Prison and community outbreak of severe respiratory infection due to adenovirus type 14p1 in Tayside, UK.

BACKGROUND: This report describes the investigation and public health management of a community-based outbreak of severe adenovirus serotype 14p1 respiratory infection affecting the Tayside area during 2011. It is the first report of an adenovirus outbreak involving prisons. METHODS: An outbreak-based/incident management approach was carried out. Alerts were sent out to local doctors, general practitioners, prison healthcare staff and consultants so that cases could be identified prospectively. Sequencing of hexon, fibre and E1A regions of adenovirus were carried out to genotype the viruses. RESULTS: Fifteen cases were identified in total, including 13 confirmed cases and 2 possible cases. There were 3 deaths amongst the 13 confirmed cases, with a case fatality rate of 23%. Eight of the cases had a direct association with one of the two prisons in the area. CONCLUSIONS: We advise that surveillance measures for adenovirus infection and guidelines for the management of critically ill patients should be developed in order to identify outbreaks at an early stage and allow patients to receive appropriate treatment. Adenovirus infection should be borne in mind as a cause of severe pneumonia in closed settings such as prisons.

Psittacosis outbreak in Tayside, Scotland, December 2011 to February 2012.

A Tayside outbreak of psittacosis December 2011­February 2012 involved three confirmed and one probable cases. Confirmed cases were indistinguishable by sequencing of polymerase chain reaction (PCR) products. The epidemiological pattern suggested person-to-person spread as illness onset dates were consistent with the incubation period and no single common exposure could explain the infections. In particular the only common exposure for a healthcare worker case is overlap in place and time with the symptomatic index case.

The impact of a managed care network on attendance, follow-up and treatment at a hepatitis C specialist centre.

Infection with the hepatitis C virus commonly occurs in patient groups who have difficulty accessing conventional medical care, reducing their chance of successful antiviral therapy. Managed care networks (MCNs) have been suggested as a mechanism of improving access to care; however, there is little evidence to support their use in patients with hepatitis C. The aim of this study was to evaluate the impact of a MCN for patients with hepatitis C. This was a retrospective cohort study of all individuals in our area who had received a positive hepatitis C antibody test between August 1994 and June 2008. The MCN introduced a new referral pathway, which included nonmedical referrals and outreach nurse-led clinics. These interventions were introduced in 2004 and evaluated in 2008. After the introduction of the MCN, the proportion of individuals who accessed care increased from 61% (280/430) to 82.4% (721/875). There was an increase in nonmedical referrals with 81 (18.3%) being directly referred from Drug Problem Services and 75 (17%) from the Prison Service. The changes to referral did not have a negative impact on treatment outcomes as the number who completed treatment increased from 66.1% (43/65) to 73.7% (98/133) and the sustained virological response increased from 50.7% (33/65) to 60.9% (81/133). This study provides evidence that the collaboration of health care professionals within a network can have a radical effect in improving access to care in a traditionally hard to reach population. This has been achieved with little additional resource, but rather working smarter with existing staff.

Hepatitis C virus infection among injecting drug users in Scotland: a review of prevalence and incidence data and the methods used to generate them.

It is estimated that of 50,000 persons in Scotland (1% of the county's population), infected with the hepatitis C virus (HCV), around 90% injected drugs. This paper reviews data on the prevalence and incidence of HCV, and the methods used to generate such information, among injecting drug users (IDUs), in Scotland. The prevalence estimate for HCV among IDUs in Scotland as a whole (44% in 2000), is comparable with those observed in many European countries. Incidence rates ranged from 11.9 to 28.4/100 person-years. The data have shaped policy to prevent infection among IDUs and have informed predictions of the number of HCV-infected IDUs who will likely progress to, and require treatment and care for, severe HCV-related liver disease. Although harm reduction interventions, in particular needle and syringe exchanges and methadone maintenance therapy, reduced the transmission of HCV among IDUs during the early to mid-1990s, incidence in many parts of the country remains high. The prevention of HCV among IDUs continues to be one of Scotland's major public health challenges.

Caesarean section versus vaginal delivery for preventing mother to infant hepatitis C virus transmission.

BACKGROUND: Observational studies have generally not provided evidence that delivery by caesarean section reduces perinatal hepatitis C virus (HCV) transmission. However, these studies have methodological weaknesses with potential for bias and their findings should be interpreted with caution. OBJECTIVES: To assess the evidence from randomised controlled trials that a policy of delivery by planned caesarean section versus vaginal delivery reduces mother to infant HCV transmission. SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (April 2006) and the Cochrane Central Register of Controlled Trials (The Cochrane Library 2006, Issue 2). SELECTION CRITERIA: Controlled trials using random or quasi-random participant allocation that compared a policy of planned elective caesarean section versus vaginal birth for mothers with HCV infection. DATA COLLECTION AND ANALYSIS: We did not identify any randomised controlled trials. MAIN RESULTS: We did not identify any randomised controlled trials. AUTHORS' CONCLUSIONS: Currently, there is no evidence from randomised controlled trials upon which to base any practice recommendations regarding planned caesarean section versus vaginal delivery for preventing mother to infant hepatitis C virus transmission. In the absence of trial data, evidence to inform women and carers is only available from observational studies that are subject to biases. Systematic review of these studies is needed. There is a need to determine whether women and healthcare providers would support a large pragmatic randomised controlled trial to provide evidence regarding the benefits and harms of planned elective caesarean section versus planned vaginal birth for women with HCV infection.

Human sealpox resulting from a seal bite: confirmation that sealpox virus is zoonotic.

The case of a marine mammal technician who sustained a seal-bite to the hand that produced a lesion clinically very similar to orf is described. Sequence analysis of the viral DNA amplified from the lesion by the polymerase chain reaction indicated that it was sealpox virus in origin. This is the first report providing unequivocal evidence that sealpox may be transmitted to humans and causes lesions very similar to orf.

Fatal human rabies caused by European bat Lyssavirus type 2a infection in Scotland.

We wish to report the first recorded case of indigenous human rabies caused by a bat bite in the United Kingdom in 100 years. This instructive case report highlights a number of key lessons: first, bites from insectivorous bats indiginous to the United Kingdom can cause rabies in humans; second, rabies immunization is essential for bat-handlers, and postexposure treatment for rabies is essential for patients bitten by bats; third, patients able to give a history who present with acute flaccid paralysis and/or presumptive viral encephalitis should be asked if they have been bitten by bats, irrespective of travel history, or this history should be obtained from family or friends; fourth, antemortem diagnosis of bat rabies (EBLV type 2a infection) in humans is possible using RT-PCR.

Prevalence of hepatitis C among injectors in Scotland 1989-2000: declining trends among young injectors halt in the late 1990s.

We previously reported a continual decline in anti-HCV prevalence among young injectors from Glasgow and Lothian between 1990 and 1997. The original study was extended to ascertain if the anti-HCV prevalence among injectors from Glasgow, Lothian, Tayside and Grampian had changed since 1997. Residual sera from injectors who had undergone attributable anti-HIV testing were tested anonymously for anti-HCV. In all four regions, no significant changes in prevalence were found among those aged < 25 years during the late 1990s (Glasgow 1997-9/00: 43%-41%; Lothian 1997-9: 13%-17%; Tayside 1997-9: 45%-35%; Grampian 1996-9: 28%-29%). Among those aged > or = 25 years, significant decreases in prevalence were only observed in Glasgow (1997-9/00: 79%-72%, P = 0.03) and Lothian (1997-9: 54%-45%, P = 0.05). The findings highlight that existing harm reduction measures, acknowledged as having helped to reduce the spread of HCV, are not sufficient to bring this epidemic under control and reduce transmission to sporadic levels.

Prevalence of antibodies to hepatitis C virus, HIV and human T-cell leukaemia/lymphoma viruses in injecting drug users in Tayside, Scotland, 1993-7.

The prevalence of blood-borne viruses in injecting drug users (IDUs) in Tayside, Scotland was determined by testing serum samples from IDUs who underwent attributable HIV antibody testing during 1993-7. The prevalence of antibodies to HIV was 29/802, (3.6%); to hepatitis C virus (HCV) 451/691, (65.3%); and to human T-cell leukaemia/lymphoma viruses type 1 and 2 (HTLV) 0/679, (0.0%). The prevalence of HIV and HCV antibodies were higher in subjects over the age of 25 (P = 0.03 and P = 0.001, respectively). During 1993-7 the prevalence of HCV fell only in younger female IDUs (P < 0.01). HIV prevalence has declined dramatically since 1985, when a rate of 40% was recorded in similar populations. Harm reduction measures have failed to control HCV the spread of infection among IDUs in Tayside, as indicated by the high proportion of antibody positive IDUs, particularly males under the age of 25. Future studies should address the nature and effective reduction of continuing risk taking among IDUs in Tayside.

Hepatitis C virus among high and low risk pregnant women in Dundee: unlinked anonymous testing.

OBJECTIVE: To determine the prevalence of the hepatitis C virus among pregnant women, to gauge the non-injecting, particularly sexual, risk of them being hepatitis C virus infected and to assess the potential impact of selective antenatal screening. POPULATION: Antenatal clinic attenders and women undergoing termination of pregnancy in 1997. SETTING: Ninewells Hospital, Dundee. DESIGN: Unlinked anonymous hepatitis C virus antibody testing of residual sera from specimens sent to the virus laboratory for routine serological testing. The results were linked to non-identifying risk information. RESULTS: Overall anti-hepatitis C virus prevalence was 0.6% (23/3,548). Prevalences among injecting drug users, non-injectors who had a sexual partner who injected, and those with neither risk respectively were 41% (7/17), 15% (5/33) and 0.3% (11/3,498). Relative risks for being an injector and a sexual partner of an injector respectively were 131 (95% CI 58-297) and 48 (95% CI 5-32). It is estimated that one of the 18 antenatal clinic attenders gave birth to an infected child. CONCLUSION: Findings suggest that non-injecting partners of injectors may be at considerable risk of acquiring hepatitis C virus sexually. Efforts to promote the use of condoms among injectors and their sexual partners should be increased. Selective anti-hepatitis C virus screening of women who reported high risk behaviour would have failed to detect half the cases. Research to gauge the views of women of childbearing age on anti-hepatitis C virus testing is required.

Acute hepatitis B in two patients transmitted from an e antigen negative cardiothoracic surgeon.

Hepatitis B virus (HBV) infection was transmitted by a locum cardiothoracic surgeon to two patients during coronary artery bypass surgery. Both patients presented 12 weeks after surgery and developed serious clinical illness. The surgeon was known to be hepatitis B surface antigen (HBsAg) positive, hepatitis B e antigen (HBeAg) negative, and to have antibodies to HBeAg (anti-HBe). Sequences of regions of the HBV surface and core genes from the patients and surgeon were indistinguishable. An exercise was undertaken to notify all patients on whom the surgeon had operated while employed at the hospital where the transmissions occurred. One hundred and twenty-three out of 126 patients were tested. No evidence of transmission to any other patient was found. Revised recommendations by the UK Health Departments as to which health care workers should be permitted to perform exposure prone procedures have recently been published.

Modified enzyme immunoassay to detect hepatitis C virus antibodies in oral fluid.

Samples of oral fluid collected from 18 patients seropositive for hepatitis C virus (HCV) and 49 seronegative patients were tested for the presence of HCV antibodies with two modified serum-screening kits. The following sensitivities and specificities were obtained: HCV 3.0 assay, 72% and 98%, respectively, and Monolisa anti-HCV assay, 100%, and 100%, respectively. The modified Monolisa assay demonstrated a striking concordance between serum and saliva samples. The use of oral fluids offers a convenient and noninvasive method applicable to HCV epidemiological studies and screening of high-risk groups.

Ante-natal screening for hepatitis B surface antigen: an appraisal of its value in a low prevalence area.

The costs and projected benefits of universal screening for hepatitis B virus (HBV) infection in pregnant women in East Anglia are calculated and compared with current practice. By adjusting data from West Midlands region for ethnicity, the prevalence of maternal hepatitis B surface-antigen (HBsAg) positivity in East Anglia is predicted to be 0.083% (1 in 1200). Published data on health risks of perinatal HBV infection and on immunisation efficacy are used to derive benefits of screening. The marginal direct cost of screening is identified from regional sources. Current clinical practice in East Anglia identifies 7 surface-antigen positive mothers per year, whereas 22 are expected. Routine antenatal screening in East Anglia would prevent 2.6 additional childhood carriers per year (compared with current practice), resulting in the prevention of 0.7 deaths per year occurring 40-50 years in the future. The direct cost per (undiscounted) life-year saved would be Pounds 2437, not including savings on treatment for chronic hepatitis B infection. Routine prenatal screening for maternal HBsAg should be introduced without delay and continue even if HBV vaccination is introduced into the UK childhood immunisation schedule.

Hepatitis C virus infection in renal dialysis patients in Glasgow.

A survey of all 483 adult dialysis patients in the three renal units in Glasgow using second-generation ELISA was carried out to determine hepatitis C virus (HCV) seroprevalence in the summer of 1991 before the introduction of blood donor screening for antibody to HCV in the UK. Supplementary testing of ELISA positive sera was by second-generation immunoblot assay (RIBA-2, Chiron). Retrospective case note analysis and testing of stored sera were performed to assess liver function and the risk factors for acquisition of the virus. Nineteen of the 483 patients (3.9%) were seropositive. Sixteen patients had been transfused and 12 had previous transplants. Seropositivity was associated with current haemodialysis (P < 0.01) rather than continuous ambulatory peritoneal dialysis (CAPD). Of those on haemodialysis, the time since first dialysis was longer for seropositives (13.6 years) than for seronegatives (6.3 years) (P < 0.01) but this did not apply to those on CAPD. Twelve of 19 (63.2%) seropositives had persistent elevations of alanine transferase compared to seven of 38 (18%) seronegative controls (P < 0.01). This large group of dialysis patients is at special risk of HCV infection but the seroprevalence is less than that reported from outside the UK despite the use of more sensitive techniques. The risk is associated with haemodialysis and is probably largely due to blood transfusion. The introduction of screening of donated blood for HCV antibody should reduce the incidence of new infection in dialysis patients.