Blood-borne virus testing in emergency departments - a systematic review of seroprevalence, feasibility, acceptability and linkage to care.

BACKGROUND: Blood-borne viruses (BBVs) cause significant morbidity and mortality worldwide. Emergency departments (EDs) offer a point of contact for groups at increased risk of BBVs who may be less likely to engage with primary care. We reviewed the literature to evaluate whether BBV testing in this setting might be a viable option to increase case finding and linkage to care. METHODS: We searched PubMed database for English language articles published until June 2019 on BBV testing in EDs. Studies reporting seroprevalence surveys, feasibility, linkage to care, enablers and barriers to testing were included. Additional searches for grey literature were performed. RESULTS: Eight-nine articles met inclusion criteria, of which 14 reported BBV seroprevalence surveys in EDs, 54 investigated feasibility and acceptability, and 36 investigated linkage to care. Most studies were HIV-focused and conducted in the USA. Seroprevalence rates were in the range 1.5-17% for HCV, 0.7-1.6% for HBV, and 0.8-13% for HIV. For studies that used an opt-in study design, testing uptake ranged from 2% to 98% and for opt-out it ranged from 16% to 91%. There was a wide range of yield: 13-100% of patients received their test result, 21-100% were linked to care, and 50-91% were retained in care. Compared with individuals diagnosed with HIV, linkage to and retention in care were lower for those diagnosed with hepatitis C. Predictors of linkage to care was associated with certain patient characteristics. CONCLUSIONS: Universal opt-out BBV testing in EDs may be feasible and acceptable, but linkage to care needs to be improved by optimizing implementation. Further economic evaluations of hepatitis testing in EDs are needed.

Two concurrent outbreaks of hepatitis A highlight the risk of infection for non-immune travellers to Morocco, January to June 2018.

From January to June 2018, two ongoing hepatitis A outbreaks affected travellers returning from Morocco and cases in Europe without travel history, resulting in 163 patients in eight European countries. Most interviewed travel-related cases were unaware of the hepatitis A risk in Morocco. Molecular analysis revealed two distinct hepatitis A virus (HAV) strains (subgenotype IA DK2018_231; subgenotype IB V18-16428). Vaccination recommendations should be emphasised to increase awareness among non-immune travellers to Morocco and HAV-endemic countries.

Hepatitis A outbreak among men who have sex with men (MSM) in England, 2016-2018: The contribution of past and current vaccination policy and practice.

BACKGROUND: We report on an outbreak of hepatitis A among men who have sex with men (MSM) in England and its associated healthcare resource burden, the strategies used to control the outbreak and the role of past and current hepatitis A vaccination policy and practice in England. METHODS: National surveillance of hepatitis A, including reference laboratory confirmation and molecular sequencing, and a case questionnaire, was enhanced in 2017 to collect demographic and risk information, disease severity and healthcare utilisation. National Health Service (NHS) data was used to calculate associated healthcare costs. RESULTS: During the outbreak period (July 2016 to January 2018), 670 confirmed cases were identified in England, caused by three distinct viral strains. The public health response included raising public and professional awareness, reinforcing vaccine recommendations for MSM, contact tracing for post-exposure vaccination, and mass community vaccination where spill-over of infection into the general population occurred. Hepatitis A vaccine was centrally procured to ensure sexual health clinics in England could offer vaccination to MSM. Outbreak associated healthcare costs were estimated to be approximately £1,500,000. CONCLUSIONS: While MSM are at increased risk of hepatitis A infection, inconsistent implementation of MSM vaccination policy in previous years led to an increasingly susceptible MSM population. The large number of cases, hospital admission rate and public health actions contributed to a significant healthcare burden. Recommending hepatitis A vaccination for MSM and clarifying commissioning responsibilities is essential to prevent future outbreaks.

Thumb abduction strength measurement in carpal tunnel syndrome.

PURPOSE: The strength of thumb abduction and index finger flexion was measured with a load cell mounted on a custom-made device. The resulting ratio (thumb-index ratio, or TIR) was used to diagnose carpal tunnel syndrome (CTS) and was compared with the gold standard (electrodiagnostic studies). The ratio was used as an internal control in each subject. METHODS: Sixty-one patients (80 hands) with a clinically and electrodiagnostically confirmed diagnosis of idiopathic CTS and a control group of 51 asymptomatic volunteers (102 hands) were evaluated. The strength of thumb abduction and index finger flexion was measured in standardized fashion in each hand three times, and the mean was taken to calculate TIR. RESULTS: Thumb-index ratio was statistically significant in differentiating between a CTS patient and a normal control. A TIR of 0.51 had a 98% specificity and a 92% positive predictive value for diagnosing CTS. Thumb-index ratio greater than 0.51 was neither sensitive nor specific for diagnosis of CTS. Twenty-four (30%) hands in the investigational group had a TIR < or =0.51 compared with 1 hand (1%) in the control group. There was a significant difference in the TIR between hands with a motor amplitude of < or =4.0 mV and those with an amplitude >4.0 mV. CONCLUSIONS: Most patients with CTS do not appear to have notable weakness of thumb abduction strength. A TIR < or =0.51 had high specificity for differentiating between CTS and controls. However, the performance of this device needs to be evaluated in a general population of patients who present with signs and symptoms of CTS before it would be clinically applicable.

Humans appear no more sensitive than laboratory animals to the inhibition of red blood cell cholinesterase by dichlorvos.

Inhibition of red blood cell (RBC) cholinesterase is a consistent and sensitive indicator of exposure to dichlorvos (DDVP). Absent human data, default 10-fold adjustment factors for potential interspecies and intraspecies sensitivity differences would be used in developing a reference dose from the no observed effect levels for this endpoint obtained in toxicological assessments of laboratory animals. However, many studies of the cholinesterase-inhibiting effects associated with DDVP exposure have been conducted in humans, including healthy male volunteers, other healthy subpopulations, and diverse clinical subpopulations. Indeed, ample human data exist to permit a data-based assessment of potential interspecies sensitivity differences in RBC cholinesterase inhibition associated with DDVP exposure. In aggregate, these data demonstrate that the DDVP doses producing inhibition in humans are virtually identical to those eliciting the same levels of inhibition in laboratory rats, mice, monkeys, and dogs. Thus, healthy humans appear to be no more sensitive than laboratory animals to DDVP's effects on RBC cholinesterase, and an interspecies uncertainty factor of 1 is appropriate and scientifically warranted for use in DDVP risk assessments.

Methods to estimate and compare VA expenditures for assistive devices to Medicare payments.

OBJECTIVE: To describe the methods used to estimate and compare Veterans Health Administration (VA) annual expenditures for assistive devices and their repair at six VA hospitals with payments for those same devices in the private sector. METHODS: Information about dispensed assistive devices and their costs was extracted from (1) the VA's National Prosthetic Patient Database, (2) each site's listing of the VA's Denver Distribution Center cost center in the Cost Distribution Jurisdictional Report, and (3) review of invoices for implanted prosthetics at each study site. We estimated private sector payments by applying Medicare geographically adjusted rates for purchases or rentals, where rates existed, or by inflating VA costs by 30%. RESULTS: The VA spent a total of $30.6 million for prosthetics at the six sites in fiscal year 1999, of which $14.2 million was for items captured in the National Prosthetic Patient Database, $3.4 million for the Denver Distribution Center, and more than $8.1 million for implants. Indirect VA costs were estimated at $4.8 million. Hypothetical private sector payments were estimated at $49.8 million. CONCLUSIONS: Unlike Medicare, VA both contracts to provide assistive devices (through a competitive bidding process) and dispenses devices it has purchased. This approach results in significantly lower expenditures, consistent with other reports. Generalizing these cost savings to other private or federal programs covering assistive devices requires further study.