Publications by authors named "Prince Adu"

18 Publications

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The impact of current opioid agonist therapy on hepatitis C virus treatment initiation among people who use drugs from in the DAA era: A population-based study.

Clin Infect Dis 2021 Jun 14. Epub 2021 Jun 14.

British Columbia Centre for Disease Control, Vancouver, BC, Canada.

Background: Evidence that opioid agonist therapy (OAT) is associated with increased odds of hepatitis C virus (HCV) treatment initiation among people who use drugs (PWUD) is emerging. The objective of this study was to determine the association between current OAT and HCV treatment initiation among PWUD in a population-level linked administrative dataset.

Methods: The British Columbia (BC) Hepatitis Testers Cohort was used for this study, which includes all people tested for or diagnosed with HCV in BC, linked to medical visits, hospitalizations, laboratory, prescription drug, and mortality data from 1992 until 2019. PWUD with injecting drug use or opioid use disorder and chronic HCV infection were identified for inclusion in this study. HCV treatment initiation was the main outcome, and subdistribution proportional hazards modeling was used to assess the relationship with current OAT.

Results: 13,803 PWUD with chronic HCV were included in this study. Among those currently on OAT at the end of the study period, 47% (2,704/5,770) had started HCV treatment, whereas 22% (1778/8033) of those not currently on OAT has started HCV treatment .. Among PWUD with chronic HCV infection, current OAT was associated with higher likelihood of HCV treatment initiation in time to event analysis (adjusted hazard ratio 1.84 [95%CI, 1.50, 2.26]).

Conclusions: Current OAT was associated with a higher likelihood of HCV treatment initiation. However, many PWUD with HCV currently receiving OAT have yet to receive HCV treatment. Enhanced integration between substance use care and HCV treatment is needed to improve the overall health of PWUD.
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http://dx.doi.org/10.1093/cid/ciab546DOI Listing
June 2021

Impact of HCV infection and ethnicity on incident type 2 diabetes: findings from a large population-based cohort in British Columbia.

BMJ Open Diabetes Res Care 2021 06;9(1)

School of Population and Public Health, The University of British Columbia, Vancouver, British Columbia, Canada

Introduction: Increasing evidence indicates that chronic hepatitis C virus (HCV) infection is associated with higher risk of diabetes. Previous studies showed ethnic disparities in the disease burden of diabetes, with increased risk in Asian population. We described the incidence of type 2 diabetes related to HCV infection and assessed the concurrent impact of HCV infection and ethnicity on the risk of diabetes.

Research Design And Methods: In British Columbia Hepatitis Testers Cohort, individuals were followed from HCV diagnosis to the earliest of (1) incident type 2 diabetes, (2) death or (3) end of the study (December 31, 2015). Study population included 847 021 people. Diabetes incidence rates in people with and without HCV were computed. Propensity scores (PS) analysis was used to assess the impact of HCV infection on newly acquired diabetes. PS-matched dataset included 117 184 people. We used Fine and Gray multivariable subdistributional hazards models to assess the effect of HCV and ethnicity on diabetes while adjusting for confounders and competing risks.

Results: Diabetes incidence rates were higher among people with HCV infection than those without. The highest diabetes incidence rate was in South Asians with HCV (14.7/1000 person-years, 95% CI 12.87 to 16.78). Compared with Others, South Asians with and without HCV and East Asians with HCV had a greater risk of diabetes. In the multivariable stratified analysis, HCV infection was associated with increased diabetes risk in all subgroups: East Asians, adjusted HR (aHR) 3.07 (95% CI 2.43 to 3.88); South Asians, aHR 2.62 (95% CI 2.10 to 3.26); and Others, aHR 2.28 (95% CI 2.15 to 2.42).

Conclusions: In a large population-based linked administrative health data, HCV infection was associated with higher diabetes risk, with a greater relative impact in East Asians. South Asians had the highest risk of diabetes. These findings highlight the need for care and screening for HCV-related chronic diseases such as type 2 diabetes among people affected by HCV.
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http://dx.doi.org/10.1136/bmjdrc-2021-002145DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8186745PMC
June 2021

Impact of direct-acting antivirals for HCV on mortality in a large population-based cohort study.

J Hepatol 2021 Jun 4. Epub 2021 Jun 4.

British Columbia Centre for Disease Control, Vancouver, BC, Canada; Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada.

Background: We evaluated the effect of sustained virologic response(SVR) from direct acting antiviral(DAA) treatments on all-cause, liver- and drug-related mortality in a population-based cohort in British Columbia(BC), Canada.

Methods: We used data from the BC Hepatitis Testers Cohort, which includes people tested for hepatitis C virus(HCV) since 1990, linked with data on medical visits, hospitalizations, prescription drugs and mortality. We followed people who received DAAs and people who did not receive any HCV treatment to death or December 31, 2019. We used inverse probability of treatment weighting(IPTW) to balance the baseline profile of treated and untreated individuals and performed multivariable proportional hazard modeling to assess effect of DAAs on mortality.

Findings: There were 10,855 people treated with DAAs (SVR: 10,426 [96%], no-SVR: 425) and 10,855 untreated individuals. Median follow-up time was 2.2 years (interquartile range: 1.3-3.6; maximum: 6.2). The all-cause mortality rate was 19.5/1000 person-years (PY) among the SVR group(deaths=552), 86.5/1000 PY among the no-SVR group (deaths=96), and 99.2/1000 PY among the untreated group (deaths=2133). In the multivariable model, SVR was associated with significant reduction in all-cause(adjusted hazard ratio[aHR]:0.19, 95%CI:0.17-0.21), liver-(subdistribution HR[asHR]:0.22, 95%CI: 0.18-0.27) and drug-related mortality(asHR: 0.26, 95%CI:0.21-0.32) compared to no-treatment. Older age and cirrhosis were associated with higher risk of liver-related mortality while younger age, injection drug use(IDU), problematic alcohol use and HIV/HBV co-infections were associated with a higher risk of drug-related mortality.

Conclusions: DAA treatment is associated with a substantial reduction in all-cause, liver- and drug-related mortality. The association of IDU and related syndemic factors with a higher risk of drug-related mortality calls for an integrated social support, addiction, and HCV care approach among people with IDU.

Lay Summary: We assessed the effect of treatment of hepatitis C virus infection with direct acting antiviral drugs on deaths from all causes, liver disease and drug use. We found that treatment with direct acting antiviral drugs is associated with substantial lowering in risk of death from all causes, liver disease and drug use among people with hepatitis C virus infection.
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http://dx.doi.org/10.1016/j.jhep.2021.05.028DOI Listing
June 2021

Towards TB elimination: how are macro-level factors perceived and addressed in policy initiatives in a high burden country?

Global Health 2021 Jan 11;17(1):11. Epub 2021 Jan 11.

School of Population and Public Health, University of British Columbia, 2206 E Mall, Vancouver, BC, V6T 1ZE, Canada.

Background: Notwithstanding extensive general discussion of the effects of upstream forces on health, there has been limited empirical examination, let alone systematic evidence documenting policy responses to such pathways in the area of tuberculosis (TB) management and control. Our study aimed to gain insight into how macro level drivers of TB are perceived by key stakeholders involved in TB management and control in a high-endemic country, and to assess how such concerns are being addressed in policy initiatives in this setting. South Africa was chosen for this case study due to our team's long-standing collaborations there, its very high burden of TB, and its introduction of a strategic plan to combat this disease.

Method: Semi-structured interviews were conducted with 20 key informants who were purposively selected for their knowledge and expertise of TB in South Africa. South Africa's National Strategic Plan for HIV, TB and STIs 2017-2022 was then reviewed to examine how identified themes from the interviews were reflected in this policy document.

Results: A history of colonization, the migrant labour system, economic inequality, poor shelter, health system challenges including TB governance, the HIV epidemic, and pertinent socio-cultural factors were all perceived to be major drivers of the epidemic. Although South Africa's current National Strategic Plan makes a firm discursive commitment to addressing the structural or macro-level drivers of TB, our analysis revealed that this commitment was not clearly reflected in projected budgetary allocations.

Conclusion: As in many other high burden settings, macro-level drivers of TB are widely recognized. Nonetheless, while micro-level (biomedical and clinical) measures, such as improving diagnostic procedures and investment in more efficacious drugs, are being (and well should be) implemented, our findings showed that macro-level drivers of TB are underrepresented in budgeting allocations for initiatives to combat this disease. Although it could be argued that structural drivers that undermine health-promoting actions are beyond the purview of the health sector itself, we argue that strategic plans to combat TB in high burden settings need more attention to directly considering such drivers to prompt the necessary changes and reduce the burden of this and other such diseases.
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http://dx.doi.org/10.1186/s12992-020-00657-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7802197PMC
January 2021

Prenatal hepatitis C screening, diagnoses, and follow-up testing in British Columbia, 2008-2019.

PLoS One 2020 31;15(12):e0244575. Epub 2020 Dec 31.

British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada.

Objective: Current guidelines in British Columbia recommend prenatal screening for hepatitis C antibodies (anti-HCV) if risk factors are present. We aimed to estimate frequency of prenatal anti-HCV testing, new diagnoses, repeated and follow-up testing among BC women.

Methods: BC Centre for Disease Control Public Health Laboratory data estimated the number of BC women (assigned female at birth or unknown sex) aged 13-49 who received routine prenatal serological screening (HIV, hepatitis B, syphilis and rubella) from 2008-2019. Anti-HCV tests ordered the same day as routine prenatal screens were considered prenatal anti-HCV tests. Assessment of follow-up was based on HCV RNA and/or genotype testing within one year of new prenatal anti-HCV diagnoses.

Results: In 2019, 55,202 routine prenatal screens were carried out for 50,392 BC women. Prenatal anti-HCV tests increased significantly, from 19.6% (9,704/49,515) in 2008 to 54.6% (27,516/50,392) in 2019 (p<0.001). New prenatal anti-HCV diagnoses (HCV positive diagnoses at first test or seroconversions) declined from 14.3% in 2008 to 10.1% in 2019. The proportion of women with new prenatal anti-HCV diagnoses that were a result of a first HCV test declined from 0.3% (29/9,701) in 2008 to 0.03% (8/27,500) in 2019. For women known to be anti-HCV positive at the time of prenatal screening, the proportion who had a prenatal anti-HCV test increased from 35.6% in 2008 to 50.8% in 2019.

Conclusion: Prenatal anti-HCV testing increased substantially over the study period. However, new HCV diagnoses remained relatively stable, suggesting that a considerable proportion of BC women with low or no risk are being screened as part of prenatal care. The vast majority of women with new HCV diagnoses receive appropriate follow-up HCV RNA and genotype testing, which may indicate interest in HCV treatment. These findings contribute to the discussion around potential for prenatal anti-HCV screening in an effort to eliminate HCV.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0244575PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7775094PMC
March 2021

HCV reinfection rates after cure or spontaneous clearance among HIV-infected and uninfected men who have sex with men.

Liver Int 2021 03 22;41(3):482-493. Epub 2020 Dec 22.

British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada.

Background & Aims: Hepatitis C virus (HCV) reinfection among high-risk groups threatens HCV elimination goals. We assessed HCV reinfection rates among men who have sex with men (MSM) in British Columbia (BC), Canada.

Methods: We used data from the BC Hepatitis Testers Cohort, which includes nearly 1.7 million individuals tested for HCV or HIV in BC. MSM who had either achieved sustained virologic response (SVR) after successful HCV treatment, or spontaneous clearance (SC) and had ≥1 subsequent HCV RNA measurement, were followed from the date of SVR or SC until the earliest of reinfection, death, or last HCV RNA measurement. Predictors of reinfection were identified by Cox proportional modelling. The earliest study start date was 6 November 1997 and latest end date was 13 April 2018.

Results: Of 1349 HCV-positive MSM who met the inclusion criteria, 493 had SC while 856 achieved SVR. 349 (25.65%) had HIV coinfection. We identified 98 reinfections during 5203 person-years (PYs) yielding a reinfection rate of 1.88/100PYs. The reinfection rate among SC (2.74/100PYs) was more than twice that of those with SVR (1.03/100 PYs). Problematic alcohol use (aHR 1.73, 95% CI 1.003-2.92), injection drug use (aHR 2.60, 95% CI 1.57-4.29) and HIV coinfection (aHR 2.04, 95% CI 1.29-3.23) were associated with increased risk of HCV reinfection. Mental health counselling history (aHR 0.24, 95% CI 0.13-0.46) was associated with reduced HCV reinfection risk.

Conclusions: There is the need to engage MSM in harm reduction and prevention services following treatment to reduce reinfection risk.
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http://dx.doi.org/10.1111/liv.14762DOI Listing
March 2021

Drug-related deaths in a population-level cohort of people living with and without hepatitis C virus in British Columbia, Canada.

Int J Drug Policy 2020 Oct 19;86:102989. Epub 2020 Oct 19.

British Columbia Centre for Disease Control, 655 West 12(th) Avenue, Vancouver, British Columbia, Canada, V5Z 4R4; School of Population and Public Health, University of British Columbia, 2206 E Mall, Vancouver, British Columbia, Canada, V6T 1Z3.

Background: The majority of new HCV infections in Canada occur in people who inject drugs. Thus, while curative direct antiviral agents (DAAs) herald a promising new era in hepatitis C virus (HCV) treatment, improving the lives and wellbeing of people living with HCV (PLHCV) must be considered in the context of reducing overdose-related harms and with a syndemic lens. We measure drug-related deaths (DRDs) among HCV-negative people and PLHCV in British Columbia (BC), Canada, and the impact of potent contaminants like fentanyl on deaths.

Methods: We identified DRDs among PLHCV and HCV-negative individuals from 2010 to 2018 in the BC Hepatitis Testers Cohort, a population-based dataset of ~1.7 million British Columbians comprising comprehensive administrative and clinical data. We estimated annual standardized liver- and drug-related mortality rates per 100,000 person-years (PY) and described the contribution of specific drugs, including fentanyl and its analogues, implicated in DRDs over time.

Results: DRDs constituted 20.1% of deaths among PLHCV and 4.7% of deaths among HCV-negative individuals; a 4.3-fold (95% confidence interval: 4.0-4.5) difference. Drug-related mortality overtook liver-related mortality for PLHCV in 2015 and HCV-negative individuals in 2016 and rose from 241.7 to 436.5 per 100,000 PY from 2010 to 2018 amongPLHCV and from 20.0 to 57.1 per 100,000 PY for HCV-negative individuals over the same period. The proportion of deaths attributable to drugs among PLHCV and HCV-negative individuals increased from 15.1% to 26.1% and 3.1% to 8.0%, in 2010 and 2018, respectively. The proportion of DRDs attributed solely to synthetic opioids such as fentanyl averaged across both groups increased from 2.1% in 2010 to 69.6% in 2017.

Conclusion: Steep drug-related mortality increases among PLHCV and HCV-negative individuals over the last decade highlight the urgent need to address overdose-related drivers and harms in these populations using an integrated care approach.
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http://dx.doi.org/10.1016/j.drugpo.2020.102989DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7569420PMC
October 2020

Syndemic profiles of people living with hepatitis C virus using population-level latent class analysis to optimize health services.

Int J Infect Dis 2020 Nov 15;100:27-33. Epub 2020 Aug 15.

School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada; BC Centre for Disease Control, Vancouver, BC, Canada; Centre for Health Evaluation and Outcome Sciences, Vancouver, BC, Canada. Electronic address:

Background: Hepatitis C (HCV) affects diverse populations such as people who inject drugs (PWID), 'baby boomers,' gay/bisexual men who have sex with men (gbMSM), and people from HCV endemic regions. Assessing HCV syndemics (i.e.relationships with mental health/chronic diseases) among subpopulations using Latent Class Analysis (LCA) may facilitate targeted program planning.

Methods: The BC Hepatitis Testers Cohort(BC-HTC) includes all HCV cases identified in BC between 1990 and 2015, integrated with medical administrative data. LCA grouped all BC-HTC HCV diagnosed people(n = 73,665) by socio-demographic/clinical indicators previously determined to be relevant for HCV outcomes. The final model was chosen based on fit statistics, epidemiological meaningfulness, and posterior probability. Classes were named by most defining characteristics.

Results: The six-class model was the best fit and had the following names and characteristics: 'Younger PWID'(n =11,563): recent IDU (67%), people born >1974 (48%), mental illness (62%), material deprivation (59%). 'Older PWID'(n =15,266): past IDU (78%), HIV (17%), HBV (17%) coinfections, alcohol misuse(68%). 'Other Middle-Aged People'(n = 9019): gbMSM (26%), material privilege (31%), people born between 1965-1974 (47%). 'People of Asian backgrounds' (n = 4718): East/South Asians (92%), no alcohol misuse (97%) or mental illness (93%), people born <1945 (26%), social privilege (66%). 'Rural baby boomers' (n = 20,401): rural dwellers (32%), baby boomers (79%), heterosexuals (99%), no HIV (100%). 'Urban socially deprived baby boomers' (n = 12,698): urban dwellers (99%), no IDU (100%), liver disease (22%), social deprivation (94%).

Conclusions: Differences between classes suggest variability in patients' service needs. Further analysis of health service utilization patterns may inform optimal service layout.
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http://dx.doi.org/10.1016/j.ijid.2020.08.035DOI Listing
November 2020

Applying equity-centered principles in an interprofessional global health course: a mixed methods study.

BMC Med Educ 2020 Jul 14;20(1):224. Epub 2020 Jul 14.

School of Population and Public Health, University of British Columbia, 2206 E Mall, Vancouver, BC, V6T 1Z3, Canada.

Background: Medical students, practitioners and other health professionals are commonly unprepared to address the many complex issues that emerge while conducting research in the Global South. As a response to identified deficiencies in global health education, a hybrid online/face-to-face multi-institutional credit course was developed based on the equity-centered principles advanced by the Canadian Coalition for Global Health Research (CCGHR), namely Authentic partnering, Inclusion, Shared benefits, Commitment to the future, Responsiveness to causes of inequities, and Humility. This study aimed to analyze the extent to which the course was effective in fortifying attitudes consistent with the CCGHR principles; identify successes and challenges; and assess how a course such as this can fill an identified gap.

Methods: This interprofessional course was offered to 25 graduate and postgraduate students in various health professions and public health. Faculty were drawn from medicine, public health, nursing and social sciences from four universities in Western Canada. A pre-post retrospective survey, key informant interviews and participant observation were used to gather data for this study.

Results: Findings showed that student attitudes regarding global health research and practice significantly evolved towards views consistent with the principles articulated. The multiple instructors and hybrid course format created both opportunities and challenges; the interprofessional nature of the cohort was considered a strong asset, as was the fact that many students came from the Global South. Some students suggested that the course could be further strengthened by concretely partnering with institutions in the Global South rather than offered solely to learners registered in universities in the Global North.

Conclusions: While weaknesses were identified, results support the conclusion that a course focused on the CCGHR principles could be useful in preparing the next generation of global health researchers and practitioners to mitigate historical limitations in this field. Longitudinal follow-up is warranted to provide more definitive conclusions.
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http://dx.doi.org/10.1186/s12909-020-02141-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7362565PMC
July 2020

Current Guidelines for Protecting Health Workers from Occupational Tuberculosis Are Necessary, but Not Sufficient: Towards a Comprehensive Occupational Health Approach.

Int J Environ Res Public Health 2020 06 3;17(11). Epub 2020 Jun 3.

School of Population and Public Health, University of British Columbia, 2206 East Mall, Vancouver, BC V6T 1Z3, Canada.

Health workers globally are at elevated occupational risk of tuberculosis infection and disease. While a raft of guidelines have been published over the past 25 years on infection prevention and control (IPC) in healthcare, studies in different settings continue to show inadequate implementation and persistence of risk. The aim of this commentary is to argue, based on the literature and our own research, that a comprehensive occupational health approach is an essential complement to IPC guidelines. Such an approach includes a health system framework focusing on upstream or mediating components, such as a statutory regulation, leadership, an information system, and staff trained in protective disciplines. Within the classical prevention framework, primary prevention needs to be complemented by occupational health services (secondary prevention) and worker's compensation (tertiary prevention). A worker-centric approach recognises the ethical implications of screening health workers, as well as the stigma perceived by those diagnosed with tuberculosis. It also provides for the voiced experience of health workers and their participation in decision-making. We argue that such a comprehensive approach will contribute to both the prevention of occupational tuberculosis and to the ability of a health system to withstand other crises of infectious hazards to its workforce
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http://dx.doi.org/10.3390/ijerph17113957DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7313452PMC
June 2020

Real-world Effectiveness of Sofosbuvir/Velpatasvir for Treatment of Chronic Hepatitis C in British Columbia, Canada: A Population-Based Cohort Study.

Open Forum Infect Dis 2020 Mar 29;7(3):ofaa055. Epub 2020 Feb 29.

British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada.

Background: Clinical trials show high efficacy of sofosbuvir/velpatasvir (SOF/VEL), but there are limited data from "real-world" settings. We aimed to evaluate SOF/VEL effectiveness for all hepatitis C virus (HCV) genotypes (GTs) in British Columbia (BC), Canada.

Methods: We used the BC Hepatitis Testers Cohort, which includes all HCV cases in the province (1990-2015) linked to administrative databases, including prescriptions to end of 2018. We measured sustained virologic response (SVR; negative RNA ≥10 weeks after treatment end) and identified characteristics associated with non-SVR. Conservatively, we excluded individuals with no assessment for SVR if their last RNA test after treatment initiation was negative (but included if positive).

Results: Of 2821 eligible participants, most were infected with GT1 (1076, 38.1%) or GT3 (1072, 38.0%), and a minority (278, 9.9%) were treated with RBV. SVR was 94.6% (2670/2821) overall and 94.5% (1017/1076) for GT1, 96.4% (512/531) for GT2, and 93.7% (1004/1072) for GT3. When disaggregated by GT, treatment regimen, and cirrhosis/treatment experience, SVR was lowest (30/40, 75.0%) among treatment-experienced GT3 individuals treated with RBV. Characteristics associated with non-SVR in multivariable analysis included younger age, RBV addition, and being a person with HIV (PWH) or who injects/injected drugs (PWID). When treatment regimen (±RBV) was removed from multivariable model, treatment experience was associated with non-SVR for GT3. Of 151 non-SVR individuals, 56.3% were nonvirological failures (treatment incomplete/no assessment for SVR) and 43.7% were virological failures (nonresponse/relapse). A disproportionately high percentage of non-SVR among PWID was due to nonvirological failure.

Conclusions: SOF/VEL was highly effective in this "real-world" population-based cohort. Additional support is required for PWID/PWH to reach SVR.
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http://dx.doi.org/10.1093/ofid/ofaa055DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7052750PMC
March 2020

Perceived Health System Barriers to Tuberculosis Control Among Health Workers in South Africa.

Ann Glob Health 2020 02 12;86(1):15. Epub 2020 Feb 12.

School of Population and Public Health, University of British Columbia, Vancouver, CA.

Background: The healthcare workforce in high tuberculosis burden countries such as South Africa is at elevated risk of tuberculosis infection and disease with adverse consequences for their well-being and productivity. Despite the availability of international guidelines on protection of health workers from tuberculosis, research globally has focused on proximal deficiencies in practice rather than on health system barriers.

Objective: This study sought to elicit perceptions of informed persons within the health system regarding health system barriers to protecting health workers from tuberculosis.

Methods: Semi-structured interviews were conducted with 18 informants active in spheres related to workplace tuberculosis prevention and management in South Africa. Interviews were audio recorded and transcribed verbatim, validated and analysed to derive emergent themes. Responses were analysed using the World Health Organization building blocks as core elements of a health system bearing on protection of its health workforce.

Findings: The following health system barriers were identified by informants: leadership and governance were "top-down" and fragmented; lack of funding was a major barrier; there were insufficient numbers of staff trained in infection prevention and control and occupational health; occupational health services were not comprehensively available and the ability to sustain protective technologies was questioned. A cross-cutting barrier was lack of priority afforded to workforce occupational health associated with lack of accurate information on cases of TB among health workers.

Conclusions: We conclude that deficiencies in implementation of recommended infection control and tuberculosis management practices are unlikely to be corrected until health system barriers are addressed. More committed leadership from senior health system management and greater funding are needed. The process could be assisted by the development of indicators to characterise such barriers and monitor progress.
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http://dx.doi.org/10.5334/aogh.2692DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7019201PMC
February 2020

Sustained virological response from interferon-based hepatitis C regimens is associated with reduced risk of extrahepatic manifestations.

J Hepatol 2019 12 6;71(6):1116-1125. Epub 2019 Aug 6.

British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada; School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada. Electronic address:

Background & Aims: HCV infection is associated with several extrahepatic manifestations (EHMs). We evaluated the impact of sustained virological response (SVR) on the risk of 7 EHMs that contribute to the burden of extrahepatic disease: type 2 diabetes mellitus, chronic kidney disease or end-stage renal disease, stroke, ischemic heart disease, major adverse cardiac events, mood and anxiety disorders, and rheumatoid arthritis.

Methods: A longitudinal cohort study was conducted using data from the British Columbia Hepatitis Testers Cohort, which included ~1.3 million individuals screened for HCV. We identified all HCV-infected individuals who were treated with interferon-based therapies between 1999 and 2014. SVR was defined as a negative HCV RNA test ≥24 weeks post-treatment or after end-of-treatment, if unavailable. We computed adjusted subdistribution hazard ratios (asHR) for the effect of SVR on each EHM using competing risk proportional hazard models. Subgroup analyses by birth cohort, sex, injection drug exposure and genotype were also performed.

Results: Overall, 10,264 HCV-infected individuals were treated with interferon, of whom 6,023 (59%) achieved SVR. Compared to those that failed treatment, EHM risk was significantly reduced among patients with SVR for type 2 diabetes mellitus (asHR 0.65; 95%CI 0.55-0.77), chronic kidney disease or end-stage renal disease (asHR 0.53; 95% CI 0.43-0.65), ischemic or hemorrhagic stroke (asHR 0.73; 95%CI 0.49-1.09), and mood and anxiety disorders (asHR 0.82; 95%CI 0.71-0.95), but not for ischemic heart disease (asHR 1.23; 95%CI 1.03-1.47), major adverse cardiac events (asHR 0.93; 95%CI 0.79-1.11) or rheumatoid arthritis (asHR 1.09; 95% CI 0.73-1.64).

Conclusions: SVR was associated with a reduction in the risk of several EHMs. Increased uptake of antiviral therapy may reduce the growing burden of EHMs in this population.

Lay Summary: We estimated the rates of chronic comorbidities other than liver disease between those who were cured and those who failed treatment for hepatitis C virus (HCV) infection. Our findings showed that the rates of these non-liver diseases were largely reduced for those who were cured with interferon-based treatments. Early HCV treatments could provide many benefits in the prevention of various HCV complications beyond liver disease.
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http://dx.doi.org/10.1016/j.jhep.2019.07.021DOI Listing
December 2019

Revisiting the healthy immigrant effect with diabetes risk in Canada: why race/ethnicity matters.

Ethn Health 2020 05 13;25(4):495-507. Epub 2019 Jan 13.

School of Communications, Simon Fraser University, Burnaby, Canada.

Evidence shows that recent immigrants are healthier than the native-born population, a phenomenon known as the healthy immigrant effect. With increasing duration of stay, this health gap significantly narrows as immigrants' health deteriorates to either resemble or become worse than the host population. However, little is known about the category of immigrants for whom this decline is most pronounced since the extant research largely considers immigrants as a homogeneous group, thus overlooking important racial/ethnic differences. Using data from the 2014 Canadian Community Health Survey (CCHS), we categorised immigrants by race/ethnicity and duration of stay in Canada and compared them to their native-born white Canadian counterparts on the likelihood of having a chronic health condition, using type 2 diabetes (T2D) as a case. In the base model, recent visible minority (i.e. non-white or non-Caucasian) immigrants and recent white immigrants were less likely than the native-born white Canadian population to have T2D (recent visible minority immigrants OR = 0.46, CI = 0.27-0.79,  = 0.005; recent white immigrants OR = 0.26, CI = 0.11-0.64,  = 0.003). The odds of having T2D were significantly higher for long-term immigrants than the native-born white Canadian population (long-term visible minority immigrants OR = 1.59, CI = 1.27-2.00,  = 0.000; long-term white immigrants OR = 1.74, CI = 1.44-2.10,  = 0.000). In the multivariate model, long-term visible minority immigrants were about 2.3 times more likely than their white Canadian born counterparts to have T2D (CI = 1.86-2.96,  = 0.000). Long-term visible minority immigrants were about 2.1 times more likely than long-term white immigrants to have T2D (CI = 1.49-2.94,  = 0.000) Immigrants' health deterioration varies significantly across ethnic categories in Canada. Interventions for facilitating the integration of visible minority immigrants may help reduce these health inequities.
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http://dx.doi.org/10.1080/13557858.2019.1567697DOI Listing
May 2020

Strengthening Human Immunodeficiency Virus and Tuberculosis Prevention Capacity among South African Healthcare Workers: A Mixed Methods Study of a Collaborative Occupational Health Program.

Saf Health Work 2018 Jun 26;9(2):172-179. Epub 2017 Aug 26.

Centre for Health Systems Research & Development, University of the Free State, Bloemfontein, South Africa.

Background: Insufficient training in infection control and occupational health among healthcare workers (HCWs) in countries with high human immunodeficiency virus (HIV) and tuberculosis (TB) burdens requires attention. We examined the effectiveness of a 1-year Certificate Program in Occupational Health and Infection Control conducted in Free State Province, South Africa in an international partnership to empower HCWs to become change agents to promote workplace-based HIV and TB prevention.

Methods: Questionnaires assessing reactions to the program and Knowledge, Attitudes, Skills, and Practices were collected pre-, mid-, and postprogram. Individual interviews, group project evaluations, and participant observation were also conducted. Quantitative data were analyzed using Wilcoxon signed-rank test. Qualitative data were thematically coded and analyzed using the Kirkpatrick framework.

Results: Participants recruited ( = 32) were mostly female (81%) and nurses (56%). Pre-to-post-program mean scores improved in knowledge (+12%,  = 0.002) and skills/practices (+14%,  = 0.002). Pre-program attitude scores were high but did not change. Participants felt empowered and demonstrated attitudinal improvements regarding HIV, TB, infection control, and occupational health. Successful projects were indeed implemented. However, participants encountered considerable difficulties in trying to sustain improvement, due largely to lack of pre-existing knowledge and experience, combined with inadequate staffing and insufficient management support.

Conclusion: Training is essential to strengthen HCWs' occupational health and infection control knowledge, attitudes, skills, and practices, and workplace-based training programs such as this can yield impressive results. However, the considerable mentorship resources required for such programs and the substantial infrastructural supports needed for implementation and sustainability of improvements in settings without pre-existing experience in such endeavors should not be underestimated.
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http://dx.doi.org/10.1016/j.shaw.2017.08.004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6005912PMC
June 2018

The Impact of a History of Adverse Childhood Experiences on Breastfeeding Initiation and Exclusivity: Findings from a National Population Health Survey.

Breastfeed Med 2016 12 11;11:544-550. Epub 2016 Oct 11.

1 Department of Obstetrics and Gynaecology and the BCCH, University of British Columbia , Vancouver, Canada .

Background: Exclusive breastfeeding is strongly recommended by the World Health Organization. Given the low rate of exclusive breastfeeding in Canada and the increasing reports of a history of adverse childhood experiences, this study sought to investigate the association between a history of adverse childhood experiences and breastfeeding initiation and breastfeeding.

Materials And Methods: Data used for this study were based on the 2011-2012 Canadian Community Health Survey, collected using a cross-sectional survey. The outcome measures were breastfeeding initiation and exclusive breastfeeding for 6 months or more. History of adverse childhood experiences was the main explanatory variable. Multivariable logistic regression models were developed to investigate the effect on breastfeeding initiation and on exclusive breastfeeding in women who gave birth within 5 years before when the surveys were conducted.

Results: The study sample included 697 and 633 women for analyses on breastfeeding initiation and breastfeeding, respectively. The proportion of women with breastfeeding initiation and exclusive breastfeeding for up to 6 months in this study were 96.8% and 42.8%, respectively. After controlling for age and highest level of education, having a history of adverse childhood experiences was not significantly associated with breastfeeding initiation (odds ratio [OR] 0.46, 95% confidence interval [CI] 0.10-1.87), but mothers with such history were less likely to exclusively breastfeed for up to 6 months compared with those without (OR 0.53, 95% CI 0.31-0.90).

Conclusions: These findings suggest the need for more breastfeeding monitoring programs beyond the hospital environment to provide more support to Canadian mothers, especially those who have experienced adverse childhood experiences or trauma in the past.
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http://dx.doi.org/10.1089/bfm.2016.0053DOI Listing
December 2016

Learning from a cluster randomized controlled trial to improve healthcare workers' access to prevention and care for tuberculosis and HIV in Free State, South Africa: the pivotal role of information systems.

Glob Health Action 2016 23;9:30528. Epub 2016 Jun 23.

National Institute for Occupational Health, A Division of the National Health Laboratory Service, Johannesburg, South Africa.

Background: Occupational tuberculosis (TB) continues to plague the healthcare workforce in South Africa. A 2-year cluster randomized controlled trial was therefore launched in 27 public hospitals in Free State province, to better understand how a combined workforce and workplace program can improve health of the healthcare workforce.

Objective: This mid-term evaluation aimed to analyze how well the intervention was being implemented, seek evidence of impact or harm, and draw lessons.

Methods: Both intervention and comparison sites had been instructed to conduct bi-annual and issue-based infection control assessments (when healthcare workers [HCW] are diagnosed with TB) and offer HCWs confidential TB and HIV counseling and testing, TB treatment and prophylaxis for HIV-positive HCWs. Intervention sites were additionally instructed to conduct quarterly workplace assessments, and also offer HCWs HIV treatment at their occupational health units (OHUs). Trends in HCW mortality, sick-time, and turnover rates (2005-2014) were analyzed from the personnel salary database ('PERSAL'). Data submitted by the OHUs were also analyzed. Open-ended questionnaires were then distributed to OHU HCWs and in-depth interviews conducted at 17 of the sites to investigate challenges encountered.

Results: OHUs reported identifying and treating 23 new HCW cases of TB amongst the 1,372 workers who used the OHU for HIV and/or TB services; 39 new cases of HIV were also identified and 108 known-HIV-positive HCWs serviced. Although intervention-site workforces used these services significantly more than comparison-site healthcare staff (p<0.001), the data recorded were incomplete for both the intervention and comparison OHUs. An overall significant decline in mortality and turnover rates was documented over this period, but no significant differences between intervention and comparison sites; sick-time data proved unreliable. Severe OHU workload as well as residual confidentiality concerns prevented the proper implementation of protocols, especially workplace assessments and data recording. Particularly, the failure to implement computerized data collection required OHU staff to duplicate their operational data collection duties by also entering research paper forms. The study was therefore halted pending the implementation of a computerized system.

Conclusions: The significant differences in OHU use documented cannot be attributable to the intervention due to incomplete data reporting; unreliable sick-time data further precluded ascertaining the benefit potentially attributable to the intervention. Computerized data collection is essential to facilitate operational monitoring while conducting real-world intervention research. The digital divide still requires the attention of researchers along with overall infrastructural constraints.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4920939PMC
http://dx.doi.org/10.3402/gha.v9.30528DOI Listing
January 2017

Association Between Recency of Immigration and Mammography Uptake: Results from a Canadian National Survey.

J Immigr Minor Health 2017 02;19(1):228-235

School of Nursing, College of Health Sciences and Professions, Ohio University, Athens, OH, USA.

Despite the strong evidence for screening mammography in reducing mortality from breast cancer, uptake is hampered especially in recent immigrant populations. Although mammography screening behaviors of immigrant populations compared to the general population have been widely studied, evidence of the specific characteristics within the immigrant population in a universal healthcare setting, which explain differential uptake is lacking. The current cross sectional study used self-reported data from the 2011-2012 Canadian Community Health Survey to examine the association between recency of immigration and mammography uptake among 1825 immigrant women aged 50-69 years, using multivariable logistic model adjusted for confounders. In the adjusted analysis, non-recent immigrants had a nonsignificantly increased odds of recent mammography uptake, 1.19 (95 % CI 0.41, 3.44) compared to recent immigrants. In the face of evidence depicting differential health care utilization of recent immigrants compared to non-recent ones or the general population, findings from this study highlight further thinking into strategies for improving the health of immigrants.
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http://dx.doi.org/10.1007/s10903-015-0298-6DOI Listing
February 2017
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