Channa R. Jayasekera

Treating hepatitis C in lower-income countries.

With costs that may exceed

Hepatitis C Treatment Delivery Mandates Optimizing Available Health Care Human Resources: A Case for Task Shifting

90,000 per course, effective new hepatitis C treatments seem beyond the reach of low- and middle-income countries. But the global rollout of HIV treatment teaches us that its possible to make these agents broadly available and affordable.

Increased Prevalence of Metabolic Risk Factors in Asian Americans With Hepatocellular Carcinoma.

This Viewpoint describes how a shortage of health care workers providing treatment for hepatitis C hinders access to treatment, despite progress in drug efficacy and reductions in drug costs.

Task-shifting – A practical strategy to improve the global access to treatment for chronic hepatitis C

Background: We used metabolic risk factors to estimate the prevalence and clinical significance of nonalcoholic fatty liver disease in Asian Americans with hepatocellular carcinoma (HCC). Methods: This is a retrospective cohort study of 824 consecutive Asian HCC patients at Stanford University Medical Center from 1998 to 2015. Patients were subdivided as: Chinese, other East Asian (Japanese and Korean), South East Asian (Vietnamese, Thai, and Laotian), Maritime South East Asian (MSEA: Malaysian, Indonesian, Filipino, and Singaporean), and South West Asian (Indian, Pakistani, and Middle Eastern). Metabolic risk factors studied were body mass index, hypertension, type II diabetes, and hyperlipidemia. Results: Most patients were male (76%) with mean age 63 years. Metabolic risk factors were highly prevalent on presentation and increased over time (P<0.001), as did the prevalence of cryptogenic HCC (P<0.004). Compared with other Asian subgroups, MSEAs had the highest body mass index (26.3) and higher rates of type II diabetes (44% vs. 23% to 35%, P=0.004), hypertension (59% vs. 38% to 55%, P=0.04), and cryptogenic HCC (15% vs. 4% to 10%, P=0.01). They were more likely to be symptomatic on presentation (44% vs. 32% to 58%, P=0.07), less likely to present within Milan criteria (34% vs. 35% to 63%, P<0.0001), and trended toward decreased 10-year survival rates compared with other ethnic subgroups (9% vs. 25% to 32%, P=0.07). Conclusions: Metabolic risk factors were increasingly prevalent among Asian Americans with HCC. MSEAs, who had the highest incidence of these risk factors, had more advanced tumor stage and trended toward worse survival.

Trends in Liver Transplantation in Hepatitis C Virus-Infected Persons, United States.

Recently, the extended role of nurses have been evaluated and reported in the International Journal of Nursing Studies through a number of research studies and reviews, including but not limited to a recent survey of advanced nursing practice roles in Australia (Gardner et al., 2016), a recent systematic review of the effectiveness of roles of advanced practice nursing in older people (Morilla-Herrera et al., 2016), a survey of clinical nurse practice roles in Canada (Kilpatrick et al., 2013), and a survey of the perceived safety of a nurse prescribing of ionising radiation (Hyde et al., 2016). In this editorial, we draw upon our clinical experience to propose an extended role for licensed vocational nurses as the primary treatment provider for patients suffering from Chronic hepatitis C. Chronic hepatitis C infection is a major contributor to the global burden of infectious diseases, with approximately 180 million patients with chronic hepatitis C worldwide, representing about 2%–3% of the population (Stanaway et al., 2016). The actual number of those infected with hepatitis C is likely underestimated given the asymptomatic nature of the disease. There has been increasing interest in initiatives to provide advanced precision healthcare to hepatitis C-infected patients with a focus on tangible benefits within two to five years and the secondary positive economic impact of the proposed intervention or platform, when implemented into clinical practice. We propose our experience with a licensed vocational nurse as the primary treatment provider for chronic hepatitis C infections, as an option to optimize the management of chronic hepatitis C globally (Jayasekera et al., 2015). A licensed vocational nurse is an entry level nursing staff who has earned a state license with a oneor two-year training program. Registered nurses and licensed vocational nurses, also known as licensed practical nurses in many states in the United States, have similar duties in caring for patients. There are, however, differences related to critical thinking skills, care planning, nursing scope of practice, education, and overall responsibilities. Registered nurses are independent in many areas, while licensed vocational nurses must work under the supervision of a registered nurses or physician. In under-resourced regions of the world where there is a shortage of specialist physicians, a nurse treatment provider model is an ideal approach to improving global access to the highly favorable safety, tolerance, and efficacy profile

Task-Shifting: An Approach to Decentralized Hepatitis C Treatment in Medically Underserved Areas

To the Editor: The Centers for Disease Control and Prevention and US Preventive Services Task Force recommend a one-time screening for hepatitis C virus (HCV) infection in adults born during 1945–1965 (birth cohort), a demographic group with a disproportionately high prevalence of HCV infection (1,2). However, some experts have warned against routine HCV screening of persons in the birth cohort, stating that this recommendation is based on unproven assumptions about the benefit of screening in reducing HCV-related mortality, given that only a minority of infected persons develop end-stage liver disease (ESLD) (3). To determine the relative effect of the birth cohort on HCV-related ESLD incidence in the United States, we analyzed trends in liver transplantation (LT) waitlist registrations and LT surgeries during 1995–2012. Using data from the United Network for Organ Sharing national registry, we evaluated birth cohort–specific (birth cohort vs. non–birth cohort) and etiology-specific (HCV vs. non-HCV) trends in LT waitlist registrations and LT surgeries performed in the United States during that 18-year period. The proportion of HCV-infected persons born during 1945–1965 among all persons with LT waitlist registrations in the United States increased from 17.8% in 1995 to 35.2% in 2012 (Table). The highest proportion of LT waitlist registrations for HCV-related ESLD was for persons in the birth cohort and increased incrementally from 61.2% in 1995 to 90.5% in 2012. The proportion of LT waitlist registrations for HCV-related ESLD among persons younger than the birth cohort was 1.0% in 1995 and 3.6% in 2012; among persons older than the birth cohort, the proportion was 37.8% in 1995 and 5.9% in 2012. Table Liver transplant waitlist additions and liver transplant recipients, United States* Similarly, among LT recipients, the proportion of HCV-infected persons born during 1945–1965 doubled from 17.4% in 1995 to 35.4% in 2012 (Table). The proportion of LT surgeries performed for HCV-related ESLD among persons in the birth cohort increased from 60.2% in 1995 to 90.7% in 2012. Among persons younger than the birth cohort, the proportion of LT surgeries performed for HCV-related ESLD was 0.7% in 1995 and 5.0% in 2012; among persons older than the birth cohort, the proportion was 39.1% in 1995 and 4.3% in 2012. During 1995–2012, the ratio of new LT waitlist registrations to LT surgeries performed for HCV-infected persons in the birth cohort remained unchanged at 1.9:2.0 despite the aging of this birth cohort. Overall trends in HCV-related LT waitlist registrations and LT surgeries stabilized during 2001–2012; the proportion of HCV-infected persons in the birth cohort increased, and the proportion of HCV-infected persons not in the birth cohort decreased. To exclude the possibility that HCV-related ESLD has always simply affected persons 50–70 years of age, we performed a subanalysis examining the proportion of LT waitlist registrations and LT surgeries for persons 50–70 years of age in each year from 1995 through 2012. During this 18-year period, among persons 50–70 years of age, new HCV-related LT waitlist registrations increased from 43.9% to 93.0%, and LT surgeries performed increased from 47.1% to 86.2%. This finding suggests that persons born during 1945–1965 are a distinct birth cohort that is increasingly affected by HCV-related ESLD. Although persons born during 1945–1965 make up an estimated 27% of the US population, they account for ≈75% of all HCV infections and 73% of HCV-associated deaths in the United (1). Our findings are consistent with those of an earlier modeling study by Davis et al. (4), which suggested that the age of persons with HCV-related cirrhosis and its complications will continue to increase. Limitations of our study include inherent limitations of retrospective design and registry data. The designation of HCV infection and birth cohort status is based entirely on data entered into the database, which are not necessarily subject to cross-checking confirmatory measures. However, any errors in data entry that may have occurred are probably nondifferential. Despite these limitations, our analysis demonstrates that >90% of HCV-infected persons registered for LT or undergoing LT surgeries in 2012 were in the birth cohort. Earlier diagnosis and preemptive cure of HCV infection with highly effective and safe direct-acting antiviral drugs may delay or reduce the need for LT among persons in the birth cohort (5). Testing and linkage to care for HCV-infected persons, particularly persons in the birth cohort, can be expected to reduce HCV-related illness and death (1,2). In response to the approval of higher efficacy antiviral drugs and rapidly rising liver failure–related death among this cohort (6,7), the use of HCV-infected donors has increased, resulting in truncated wait times for HCV-infected LT recipients in many regions (8), whereas HCV-uninfected persons are generally waiting considerably longer, often years, for HCV-uninfected donors (9). This phenomenon is another index of the extent of HCV-related ESLD in the United States.