WHO Elimination Targets Research Articles

Strategies to eliminate hepatitis C in Croatia, a modelling study

Background: Since a 2016 analysis on the epidemiology and disease burden of HCV in Croatia, the HCV treatment paradigm has shifted substantially. Fibrosis restrictions were removed, and the number of patients treated tripled. With these encouraging changes to policy and practice, an updated analysis was completed to guide resource allocation and a national strategic plan for HCV elimination in Croatia. Methods: A comprehensive literature review and discussions with in-country experts were used to identify epidemiological factors defining HCV disease burden in Croatia. An HCV disease burden model, seeded with this data, was used to assess the impact of increasing screening rates and delineate the steps needed to reach the World Health Organization’s (WHO) Global Health and Sector Strategy hepatitis C elimination targets. Results: Achieving WHO elimination targets would reduce the number of viremic cases of HCV from 21,000 in 2015 to 4,000 by 2030 while averting 500 liver-related deaths, and 680 cases of hepatocellular carcinoma and decompensated cirrhosis from 2015 to 2030, relative to the projections under the current standard of care. Screening practices will need to ramp up to testing about 250,000 Croatians annually so that about 1,500 patients can be diagnosed and treated each year. Conclusions: Elimination requires a coordinated effort between country and industry leaders including government authorities, policymakers and healthcare and insurance providers. Improved screening mechanisms will be needed for the scale-up required to achieve goals.

Towards the trachoma elimination target in the Southern region of Ethiopia: How well is the SAFE strategy being implemented?

Trachoma is one of the 20 neglected tropical diseases and a serious public health problem in Ethiopia. To reach the WHO elimination target by 2020, SAFE (Surgery, Antibiotics, Facial cleanliness, Environmental improvement) strategy has been implemented in the Southern Nations, Nationalities, and Peoples' Region (SNNPRs), Ethiopia. Scarce evidence exists regarding recent progress in achieving elimination of active trachoma (< 5%) and how well the SAFE strategy implemented. A retrospective analysis of programmatic data in the period 2013-2018 was used. All trachoma endemic districts in SNNPR were included. Data collected from the Federal Ministry of Health on trachoma prevalence and SAFE strategy were analyzed. Out of 134 endemic districts, only 35 had their planned impact survey, of which only 11 districts achieved the elimination target. Six districts reverted backwards from eliminated status to low (1) or moderate (5) level. The median prevalence of active trachoma in these 35 districts was 10% in 2017/18. In 2017, the mean antibiotic treatment coverage was 90%, but only 56% and 68% of districts implemented and reported on "F" and "E" components, respectively. In the high prevalence districts, only 10% delivered their planned five rounds of Zithromax® mass distribution. These data showed a lack in planned impact surveys with only a limited number of districts reached the WHO elimination threshold by 2018. Lack of attention on high prevalent districts, and recent reversal of trachoma eliminated districts to moderate or low prevalence levels argue for urgent and prioritized implementation of the SAFE strategy.

Hepatitis C elimination in the Netherlands (CELINE): study protocol for nationwide retrieval of lost to follow-up patients with chronic hepatitis C

BackgroundThe Netherlands has a low hepatitis C virus (HCV) prevalence, estimated at 0.16%. Previous studies have shown that up to 30% of the diagnosed HCV population in the Netherlands has...

Effects and cost of different strategies to eliminate hepatitis C virus transmission in Pakistan: a modelling analysis

The WHO elimination strategy for hepatitis C virus advocates scaling up screening and treatment to reduce global hepatitis C incidence by 80% by 2030, but little is known about how this reduction could be achieved and the costs of doing so. We aimed to evaluate the effects and cost of different strategies to scale up screening and treatment of hepatitis C in Pakistan and determine what is required to meet WHO elimination targets for incidence. We adapted a previous model of hepatitis C virus transmission, treatment, and disease progression for Pakistan, calibrating using available data to incorporate a detailed cascade of care for hepatitis C with cost data on diagnostics and hepatitis C treatment. We modelled the effect on various outcomes and costs of alternative scenarios for scaling up screening and hepatitis C treatment in 2018-30. We calibrated the model to country-level demographic data for 1960-2015 (including population growth) and to hepatitis C seroprevalence data from a national survey in 2007-08, surveys among people who inject drugs (PWID), and hepatitis C seroprevalence trends among blood donors. The cascade of care in our model begins with diagnosis of hepatitis C infection through antibody screening and RNA confirmation. Diagnosed individuals are then referred to care and started on treatment, which can result in a sustained virological response (effective cure). We report the median and 95% uncertainty interval (UI) from 1151 modelled runs. One-time screening of 90% of the 2018 population by 2030, with 80% referral to treatment, was projected to lead to 13·8 million (95% UI 13·4-14·1) individuals being screened and 350 000 (315 000-385 000) treatments started annually, decreasing hepatitis C incidence by 26·5% (22·5-30·7) over 2018-30. Prioritised screening of high prevalence groups (PWID and adults aged ≥30 years) and rescreening (annually for PWID, otherwise every 10 years) are likely to increase the number screened and treated by 46·8% and decrease incidence by 50·8% (95% UI 46·1-55·0). Decreasing hepatitis C incidence by 80% is estimated to require a doubling of the primary screening rate, increasing referral to 90%, rescreening the general population every 5 years, and re-engaging those lost to follow-up every 5 years. This approach could cost US$8·1 billion, reducing to $3·9 billion with lowest costs for diagnostic tests and drugs, including health-care savings, and implementing a simplified treatment algorithm. Pakistan will need to invest about 9·0% of its yearly health expenditure to enable sufficient scale up in screening and treatment to achieve the WHO hepatitis C elimination target of an 80% reduction in incidence by 2030. UNITAID.

Scaling up screening and treatment for elimination of hepatitis C among men who have sex with men in the era of HIV pre-exposure prophylaxis

BackgroundRoutine HIV pre-exposure prophylaxis (PrEP) and HIV care appointments provide opportunities for screening men who have sex with men (MSM) for hepatitis C virus infection (HCV). However, levels of screening required for achieving the WHO elimination target of reducing HCV incidence by 90% by 2030 among all MSM are unknown. MethodsAn HCV/HIV transmission model was calibrated to UK prevalence of HIV among MSM (4·7%) and chronic HCV infection among HIV-positive MSM (9·9%) and HIV-negative MSM (1.2%). Assuming 12·5% coverage of PrEP among HIV-negative MSM, we evaluated the relative reduction in overall HCV incidence by 2030 (compared to 2018 levels) of HCV screening every 12/6-months (alongside completing direct acting antiviral treatment within 6-months of diagnosis) in PrEP users and/or HIV-diagnosed MSM. We estimated the additional screening required among HIV-negative non-PrEP users to reduce overall incidence by 90% by 2030. The effect of 50% reduction in condom use among PrEP users (risk compensation) was estimated. ResultsScreening and treating PrEP users for HCV every 12 or 6-months decreases HCV incidence by 67·3% (uncertainty range 52·7–79·2%) or 70·2% (57·1–80·8%), respectively, increasing to 75·4% (59·0–88·6%) or 78·8% (63·9–90·4%) if HIV-diagnosed MSM are also screened at same frequencies. Risk compensation reduces these latter projections by <10%. To reduce HCV incidence by 90% by 2030 without risk compensation, HIV-negative non-PrEP users require screening every 5·6 (3·8–9·2) years if MSM on PrEP and HIV-diagnosed MSM are screened every 6-months, shortening to 4·4 (3·1–6·6) years with risk compensation. For 25·0% PrEP coverage, the HCV elimination target can be reached without screening HIV-negative MSM not on PrEP, irrespective of risk compensation. InterpretationAt low PrEP coverage, increased screening of all MSM is required to achieve the WHO HCV-elimination targets for MSM in the UK, whereas at higher PrEP coverage this is possible through just screening HIV-diagnosed MSM and PrEP users.

2898. Achieving Hepatitis C SVR12 of 95% in Mono-Infected Patients with Severe Comorbidities Using Volunteer Staff and Minimal Clinic Visits and Phlebotomy

BackgroundHCV is the most common chronic bloodborne infection in the United States with an estimated 3.5 million infected. With direct-acting antivirals, cure can be achieved in 8 to 12 weeks. To achieve WHO elimination targets by 2030 (>90% reduction in incidence) requires increased detection, access to care, and simpler treatment protocols that patients, challenged by substance use and mental health disorders, can readily complete.MethodsIn 2016, Wake County, NC began HCV testing at 32 sites finding prevalence >10% at 5 shelters and drug treatment centers. An adapted simplified HCV treatment protocol, used in the high prevalence settings of Ukraine and Burma, was implemented at the Open Door Clinic – a free clinic for uninsured persons living in poverty in Wake County. After initially using genotype-specific therapy, we switched to pan-genotypic sofosbuvir/velapatisvir (SOF/VEL) for 12 weeks. Clinic visits were limited to pre-treatment and 12 weeks after treatment completion. Patients were contacted weekly via text to check on their health and adherence.ResultsThirty HCV mono-infected patients have initiated treatment including 9 women. 21 were infected by IDU, 5 by transfusion, 3 by sex with an infected partner, and 5 have unknown risk. In genotype (GT) testing 22 have GT1, 3 GT 2, and 4 GT3. Major comorbidities include 24 with current or recent IDU, alcohol dependency, psychotic depression or schizophrenia, or missing all medical appointments other than the HCV. Twenty-seven of 30 have completed their prescribed course of HCV therapy and 20 have achieved an SVR at 12 weeks. The 1 patient who failed was admitted to the hospital 4 times in the first 6 weeks of treatment and did not take his medication consistently. An additional 2 remain on treatment and 6 are awaiting results of testing done at 12 weeks post-therapy completion. One patient died within 2 weeks of initiating therapy due to a perforated duodenal ulcer.ConclusionUsing targeted on-site HCV testing, we identified high prevalence sites. Implementing a simplified HCV treatment program reduces patient and clinic burden and resulted in 95% achieving SVR12 despite severe comorbidities. Expansion of this program to other clinics in Wake County is underway.Disclosures All Authors: No reported Disclosures.

Consistent high prevalence of undiagnosed blood-borne virus infection in patients attending large urban emergency departments in England.

Understanding local viral hepatitis and HIV epidemiology is essential if WHO elimination targets are to be achieved. We demonstrate a consistently high prevalence of undiagnosed active infection in urban emergency department attendees in England, with variations in local risk groups crucial to informing targeted testing initiatives.

The case for a universal hepatitis C vaccine to achieve hepatitis C elimination

BackgroundThe introduction of highly effective direct-acting antiviral (DAA) therapy for hepatitis C has led to calls to eliminate it as a public health threat through treatment-as-prevention. Recent studies suggest it is possible to develop a vaccine to prevent hepatitis C. Using a mathematical model, we examined the potential impact of a hepatitis C vaccine on the feasibility and cost of achieving the global WHO elimination target of an 80% reduction in incidence by 2030 in the era of DAA treatment.MethodsThe model was calibrated to 167 countries and included two population groups (people who inject drugs (PWID) and the general community), features of the care cascade, and the coverage of health systems to deliver services. Projections were made for 2018–2030.ResultsThe optimal incidence reduction strategy was to implement test and treat programmes among PWID, and in settings with high levels of community transmission undertake screening and treatment of the general population. With a vaccine available, the optimal strategy was to include vaccination within test and treat programmes, in addition to vaccinating adolescents in settings with high levels of community transmission. Of the 167 countries modelled, between 0 and 48 could achieve an 80% reduction in incidence without a vaccine. This increased to 15–113 countries if a 75% efficacious vaccine with a 10-year duration of protection were available. If a vaccination course cost US$200, vaccine use reduced the cost of elimination for 66 countries (40%) by an aggregate of US$7.4 (US$6.6–8.2) billion. For a US$50 per course vaccine, this increased to a US$9.8 (US$8.7–10.8) billion cost reduction across 78 countries (47%).ConclusionsThese findings strongly support the case for hepatitis C vaccine development as an urgent public health need, to ensure hepatitis C elimination is achievable and at substantially reduced costs for a majority of countries.

Leprosy in the post-elimination phase: so near and yet so far

Leprosy is a chronic infectious disease affecting primarily the skin and peripheral nerves. WHO multi-drug therapy launched in 1982 revolutionized the treatment of this old age scourge, paving the way for leprosy elimination at global and national level. The global prevalence came down from over 5 million cases in the 1980s to less than 200,000 at the end of 2016. At present, India, Brazil and Indonesia are the top three countries with maximum leprosy load. The Indian national leprosy programme achieved the prevalence rate of less than 1/10,000 in the year 2005 but even after decade of attaining the WHO elimination target, India still contributes over 50% of the cases to the global leprosy burden leading the pack. Despite achieving the elimination target, the incidence of the disease has not come down as new cases continue to be reported or have plateaued worldwide. Adding to the boil is the persistence of social disparity and shadow of discriminatory laws in the statute books of many countries. Although significant success has been achieved in leprosy control over the years, but as the old adage goes, 'the last lap is the hardest and requires special efforts'. WHO global leprosy strategy 2016-2020 has a vision to achieve "the three zeros": zero disease, zero disability and zero discrimination. The present review focuses on the global and national leprosy scenario, changes made in the leprosy programme in the post-elimination phase and its consequences particularly in India, new scientific advances/insights and global and national strategies to deal with the hurdles in the road towards a "leprosy free world".

How can we achieve WHO's elimination target for hepatitis C incidence?

How can we achieve WHO's elimination target for hepatitis C incidence?

Scaling up prevention and treatment towards the elimination of hepatitis C: a global mathematical model

SummaryBackgroundThe revolution in hepatitis C virus (HCV) treatment through the development of direct-acting antivirals (DAAs) has generated international interest in the global elimination of the disease as a public health threat. In 2017, this led WHO to establish elimination targets for 2030. We evaluated the impact of public health interventions on the global HCV epidemic and investigated whether WHO's elimination targets could be met.MethodsWe developed a dynamic transmission model of the global HCV epidemic, calibrated to 190 countries, which incorporates data on demography, people who inject drugs (PWID), current coverage of treatment and prevention programmes, natural history of the disease, HCV prevalence, and HCV-attributable mortality. We estimated the worldwide impact of scaling up interventions that reduce risk of transmission, improve access to treatment, and increase screening for HCV infection by considering six scenarios: no change made to existing levels of diagnosis or treatment; sequentially adding the following interventions: blood safety and infection control, PWID harm reduction, offering of DAAs at diagnosis, and outreach screening to increase the number diagnosed; and a scenario in which DAAs are not introduced (ie, treatment is only with pegylated interferon and oral ribavirin) to investigate the effect of DAA use. We explored the effect of varying the coverage or impact of these interventions in sensitivity analyses and also assessed the impact on the global epidemic of removing certain key countries from the package of interventions.FindingsBy 2030, interventions that reduce risk of transmission in the non-PWID population by 80% and increase coverage of harm reduction services to 40% of PWID could avert 14·1 million (95% credible interval 13·0–15·2) new infections. Offering DAAs at time of diagnosis in all countries could prevent 640 000 deaths (620 000–670 000) from cirrhosis and liver cancer. A comprehensive package of prevention, screening, and treatment interventions could avert 15·1 million (13·8–16·1) new infections and 1·5 million (1·4–1·6) cirrhosis and liver cancer deaths, corresponding to an 81% (78–82) reduction in incidence and a 61% (60–62) reduction in mortality compared with 2015 baseline. This reaches the WHO HCV incidence reduction target of 80% but is just short of the mortality reduction target of 65%, which could be reached by 2032. Reducing global burden depends upon success of prevention interventions, implemention of outreach screening, and progress made in key high-burden countries including China, India, and Pakistan.InterpretationFurther improvements in blood safety and infection control, expansion or creation of PWID harm reduction services, and extensive screening for HCV with concomitant treatment for all are necessary to reduce the burden of HCV. These findings should inform the ongoing global action to eliminate the HCV epidemic.FundingWellcome Trust.

Mathematical modeling of hepatitis c virus (HCV) prevention among people who inject drugs: A review of the literature and insights for elimination strategies

In 2016, the World Health Organization issued global elimination targets for hepatitis C virus (HCV), including an 80% reduction in HCV incidence by 2030. The vast majority of new HCV infections occur among people who inject drugs (PWID), and as such elimination strategies require particular focus on this population. As governments urgently require guidance on how to achieve elimination among PWID, mathematical modeling can provide critical information on the level and targeting of intervention are required. In this paper we review the epidemic modeling literature on HCV transmission and prevention among PWID, highlight main differences in mathematical formulation, and discuss key insights provided by these models in terms of achieving WHO elimination targets among PWID. Overall, the vast majority of modeling studies utilized a deterministic compartmental susceptible-infected-susceptible structure, with select studies utilizing individual-based network transmission models. In general, these studies found that harm reduction alone is unlikely to achieve elimination targets among PWID. However, modeling indicates elimination is achievable in a wide variety of epidemic settings with harm reduction scale-up combined with modest levels of HCV treatment for PWID. Unfortunately, current levels of testing and treatment are generally insufficient to achieve elimination in most settings, and require further scale-up. Additionally, network-based treatment strategies as well as prison-based treatment and harm reduction provision could provide important additional population benefits. Overall, epidemic modeling has and continues to play a critical role in informing HCV elimination strategies worldwide.

HCV core antigen: toward elimination of nucleic acid testing?

Following the advent of highly effective direct-acting antivirals (DAAs), now available at generic prices in most countries, elimination of hepatitis C virus (HCV) has become a global health priority. 1 WHOGlobal health sector strategy on viral hepatitis 2016–2021: towards ending viral hepatitis. http://apps.who.int/iris/bitstream/10665/246177/1/WHO-HIV-2016.06-eng.pdfDate: June, 2016 Date accessed: September 10, 2018 Google Scholar However, the very small proportion of patients with HCV being tested and treated for hepatitis C globally overshadows the ambitious 2030 WHO elimination targets. Approximately 20% of patients with HCV are aware of their diagnosis, and less than 10% were treated for their infection in 2015; therefore, achieving the 80% treatment coverage goal recommended by WHO is still a long way off. 1 WHOGlobal health sector strategy on viral hepatitis 2016–2021: towards ending viral hepatitis. http://apps.who.int/iris/bitstream/10665/246177/1/WHO-HIV-2016.06-eng.pdfDate: June, 2016 Date accessed: September 10, 2018 Google Scholar HCV core antigen as an alternative to HCV RNA testing in the era of direct-acting antivirals: retrospective screening and diagnostic cohort studiesThese data support the use of HCV core antigen testing to document HCV viraemia in a cost-saving diagnostic algorithm. In a treatment setting, HCV core antigen testing can be used instead of HCV RNA testing for diagnosis and documentation of treatment adherence, but it might not be adequate to determine SVR. This approach might improve access to care, particularly in low-income and middle-income countries. Full-Text PDF

Australia on track to achieve WHO elimination targets following rapid initial DAA treatment uptake

Australia on track to achieve WHO elimination targets following rapid initial DAA treatment uptake

Elimination of visceral leishmaniasis in the Indian subcontinent: a comparison of predictions from three transmission models

We present three transmission models of visceral leishmaniasis (VL) in the Indian subcontinent (ISC) with structural differences regarding the disease stage that provides the main contribution to transmission, including models with a prominent role of asymptomatic infection, and fit them to recent case data from 8 endemic districts in Bihar, India. Following a geographical cross-validation of the models, we compare their predictions for achieving the WHO VL elimination targets with ongoing treatment and vector control strategies. All the transmission models suggest that the WHO elimination target (<1 new VL case per 10,000 capita per year at sub-district level) is likely to be met in Bihar, India, before or close to 2020 in sub-districts with a pre-control incidence of 10 VL cases per 10,000 people per year or less, when current intervention levels (60% coverage of indoor residual spraying (IRS) of insecticide and a delay of 40days from onset of symptoms to treatment (OT)) are maintained, given the accuracy and generalizability of the existing data regarding incidence and IRS coverage. In settings with a pre-control endemicity level of 5/10,000, increasing the effective IRS coverage from 60 to 80% is predicted to lead to elimination of VL 1–3 years earlier (depending on the particular model), and decreasing OT from 40 to 20days to bring elimination forward by approximately 1year. However, in all instances the models suggest that L. donovani transmission will continue after 2020 and thus that surveillance and control measures need to remain in place until the longer-term aim of breaking transmission is achieved.

Spatial distribution of leprosy in Nigeria

Despite achieving the WHO elimination target of less than 1/10,000 population in 1998 at the national level, there are still pockets of relative high endemicity of leprosy in Nigeria. This study used spatial analytic techniques to determine the spatial distribution of leprosy in Nigeria. The study is an ecological study of secondary data of new leprosy cases reported to the National TB and Leprosy Control Programme (NTBLCP) in Nigeria, 2010–2014. The 36 states and Federal Capital Territory were used as the unit of geographical analysis. The global Moran’s I and Local Moran’s I (LISA) test were used to measure spatial autocorrelation and significant levels were taken at P < , 0·05. A total of 17,356 new leprosy cases were notified over 5 years (2010–2014) in Nigeria. A majority of the cases were multi-bacillary 16,037 (92·4%) while 1319 (7·6%) were pauci-bacillary. A total of 1569 (9%) children were reported with leprosy. The leprosy case detection rate increased slightly from 2·21/100,000 in 2010 to 2·24/100,000 in 2012 and declined to 1·66/100,000 population in 2014. Significant clustering of average annual leprosy case detection rate was observed in Kebbi state only, while childhood leprosy was significantly clustered in four states namely Sokoto, Kebbi, Rivers and Zamfara states. The study observed a significant clustering of leprosy case detection rate in Nigeria. The findings can serve as a useful guide to the national leprosy control programme for efficient use of scarce resources to target interventions to priority states for the elimination of leprosy in the country.

Treatment scale-up to achieve global HCV incidence and mortality elimination targets: a cost-effectiveness model

AimsThe WHO's draft HCV elimination targets propose an 80% reduction in incidence and a 65% reduction in HCV-related deaths by 2030. We estimate the treatment scale-up required and cost-effectiveness of...

Leprosy in Mpumalanga Province, South Africa—eliminated or hidden?

In South Africa, leprosy has been a notifiable condition since 1921. Although the WHO elimination target of less than one case per 10,000 population has been achieved at country level, the distribution of leprosy in the country is distinctly heterogeneous, with a prominent 'leprosy belt' of greater prevalence stretching across Mpumalanga Province into northern Kwa-Zulu Natal. The highest prevalence in this 'belt' has historically been in Ermelo District. Recent trends of few newly detected leprosy patients in this district raised concerns that health system changes may have resulted in failure to detect leprosy cases. Thus a large-scale community awareness campaign was conducted followed by an intensively advertised screening programme of 3-month duration at schools and central gathering points in villages and farms from 1 June to 31 August 2000. One thousand one hundred and seventy-seven people presented for clinical screening at designated points, while 790 scholars were screened at schools and an additional 1433 people were screened at their homes by the field team. Forty-four people with skin or nervous system lesions compatible with leprosy were referred for specialized assessment and biopsy where indicated. Four new leprosy patients were diagnosed, including an elderly lady with pronounced disability. Two of these patients had prior contact with the health service due to dermatological manifestations of leprosy without diagnosis being made. All patients provided a history of close prolonged contact with known leprosy patients. Ongoing intense tracing and follow-up of close contacts of proven leprosy cases may be a more efficient method of detecting leprosy cases in areas with relatively stable populations that have accomplished 'leprosy elimination', than resource intensive community surveys.