Publications by authors named "Zahid A Butt"

33 Publications

Elevated risk of colorectal, liver, and pancreatic cancers among HCV, HBV and/or HIV (co)infected individuals in a population based cohort in Canada.

Ther Adv Med Oncol 2021 11;13:1758835921992987. Epub 2021 Feb 11.

BC Centre for Disease Control, Vancouver, Canada.

Introduction: Studies of the impact of hepatitis C virus (HCV), hepatitis B virus (HBV) and HIV mono and co-infections on the risk of cancer, particularly extra-hepatic cancer, have been limited and inconsistent in their findings.

Methods: In the British Columbia Hepatitis Testers Cohort, we assessed the risk of colorectal, liver, and pancreatic cancers in association with HCV, HBV and HIV infection status. Using Fine and Gray adjusted proportional subdistribution hazards models, we assessed the impact of infection status on each cancer, accounting for competing mortality risk. Cancer occurrence was ascertained from the BC Cancer Registry.

Results: Among 658,697 individuals tested for the occurrence of all three infections, 1407 colorectal, 1294 liver, and 489 pancreatic cancers were identified. Compared to uninfected individuals, the risk of colorectal cancer was significantly elevated among those with HCV (Hazard ration [HR] 2.99; 95% confidence interval [CI] 2.55-3.51), HBV (HR 2.47; 95% CI 1.85-3.28), and HIV mono-infection (HR 2.30; 95% CI 1.47-3.59), and HCV/HIV co-infection. The risk of liver cancer was significantly elevated among HCV and HBV mono-infected and all co-infected individuals. The risk of pancreatic cancer was significantly elevated among individuals with HCV (HR 2.79; 95% CI 2.01-3.70) and HIV mono-infection (HR 2.82; 95% CI 1.39-5.71), and HCV/HBV co-infection.

Discussion/conclusion: Compared to uninfected individuals, the risk of colorectal, pancreatic and liver cancers was elevated among those with HCV, HBV and/or HIV infection. These findings highlight the need for targeted cancer prevention and diligent clinical monitoring for hepatic and extrahepatic cancers in infected populations.
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http://dx.doi.org/10.1177/1758835921992987DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7887683PMC
February 2021

What social media told us in the time of COVID-19: a scoping review.

Lancet Digit Health 2021 03 28;3(3):e175-e194. Epub 2021 Jan 28.

School of Public Health and Health Systems, University of Waterloo, Waterloo, ON, Canada. Electronic address:

With the onset of the COVID-19 pandemic, social media has rapidly become a crucial communication tool for information generation, dissemination, and consumption. In this scoping review, we selected and examined peer-reviewed empirical studies relating to COVID-19 and social media during the first outbreak from November, 2019, to November, 2020. From an analysis of 81 studies, we identified five overarching public health themes concerning the role of online social media platforms and COVID-19. These themes focused on: surveying public attitudes, identifying infodemics, assessing mental health, detecting or predicting COVID-19 cases, analysing government responses to the pandemic, and evaluating quality of health information in prevention education videos. Furthermore, our Review emphasises the paucity of studies on the application of machine learning on data from COVID-19-related social media and a scarcity of studies documenting real-time surveillance that was developed with data from social media on COVID-19. For COVID-19, social media can have a crucial role in disseminating health information and tackling infodemics and misinformation.
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http://dx.doi.org/10.1016/S2589-7500(20)30315-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7906737PMC
March 2021

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

Liver Int 2021 Mar 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

Concurrent Hepatitis C and B Virus and Human Immunodeficiency Virus Infections Are Associated With Higher Mortality Risk Illustrating the Impact of Syndemics on Health Outcomes.

Open Forum Infect Dis 2020 Sep 13;7(9):ofaa347. Epub 2020 Aug 13.

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

Background: Hepatitis C virus (HCV), hepatitis B virus (HBV), and human immunodeficiency virus (HIV) infections are associated with significant mortality globally and in North America. However, data on impact of concurrent multiple infections on mortality risk are limited. We evaluated the effect of HCV, HBV, and HIV infections and coinfections and associated factors on all-cause mortality in British Columbia (BC), Canada.

Methods: The BC Hepatitis Testers Cohort includes ~1.7 million individuals tested for HCV or HIV, or reported as a case of HCV, HIV, or HBV from 1990 to 2015, linked to administrative databases. We followed people with HCV, HBV, or HIV monoinfection, coinfections, and triple infections from their negative status to date of death or December 31, 2016. Extended Cox proportional hazards regression was used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for factors associated with all-cause mortality.

Results: Of 658 704 individuals tested for HCV, HBV, and HIV, there were 33 804 (5.13%) deaths. In multivariable Cox regression analysis, individuals with HCV/HBV/HIV (HR, 8.9; 95% CI, 8.2-9.7) infections had the highest risk of mortality followed by HCV/HIV (HR, 4.8; 95% CI, 4.4-5.1), HBV/HIV (HR, 4.1; 95% CI, 3.5-4.8), HCV/HBV (HR, 3.9; 95% CI, 3.7-4.2), HCV (HR, 2.6; 95% CI, 2.6-2.7), HBV (HR, 2.2; 95% CI, 2.0-2.3), and HIV (HR, 1.6; 95% CI, 1.5-1.7). Additional factors associated with mortality included injection drug use, problematic alcohol use, material deprivation, diabetes, chronic kidney disease, heart failure, and hypertension.

Conclusions: Concurrent multiple infections are associated with high mortality risk. Substance use, comorbidities, and material disadvantage were significantly associated with mortality independent of coinfection. Preventive interventions, including harm reduction combined with coinfection treatments, can significantly reduce mortality.
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http://dx.doi.org/10.1093/ofid/ofaa347DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7489531PMC
September 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

Correction: Considerations for an Individual-Level Population Notification System for Pandemic Response: A Review and Prototype.

J Med Internet Res 2020 Jun 22;22(6):e21634. Epub 2020 Jun 22.

School of Public Health and Health Systems, University of Waterloo, Waterloo, ON, Canada.

[This corrects the article DOI: 10.2196/19930.].
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http://dx.doi.org/10.2196/21634DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7381056PMC
June 2020

Considerations for an Individual-Level Population Notification System for Pandemic Response: A Review and Prototype.

J Med Internet Res 2020 06 5;22(6):e19930. Epub 2020 Jun 5.

School of Public Health and Health Systems, University of Waterloo, Waterloo, ON, Canada.

The outbreak of the coronavirus disease (COVID-19), caused by severe acute respiratory syndrome coronavirus 2, spread worldwide after its emergence in China. Whether rich or poor, all nations are struggling to cope with this new global health crisis. The speed of the threat's emergence and the quick response required from public health authorities and the public itself makes evident the need for a major reform in pandemic surveillance and notification systems. The development and implementation of a graded, individual-level pandemic notification system could be an effective tool to combat future threats of epidemics. This paper describes a prototype model of such a notification system and its potential advantages and challenges for implementation. Similar to other emergency alerts, this system would include a number of threat levels (level 1-5) with a higher level indicating increasing severity and intensity of safety measures (eg, level 1: general hygiene, level 2: enhanced hygiene, level 3: physical distancing, level 4: shelter in place, and level 5: lockdown). The notifications would be transmitted to cellular devices via text message (for lower threat levels) or push notification (for higher threat levels). The notification system would allow the public to be informed about the threat level in real time and act accordingly in an organized manner. New Zealand and the United Kingdom have recently launched similar alert systems designed to coordinate the ongoing COVID-19 pandemic response more efficiently. Implementing such a system, however, faces multiple challenges. Extensive preparation and coordination among all levels of government and relevant sectors are required. Additionally, such systems may be effective primarily in countries where there exists at least moderate trust in government. Advance and ongoing public education about the nature of the system and its steps would be an essential part of the system, such that all members of the public understand the meaning of each step in advance, similar to what has been established in systems for other emergency responses. This educational component is of utmost importance to minimize adverse public reaction and unintended consequences. The use of mass media and local communities could be considered where mobile phone penetration is low. The implementation of such a notification system would be more challenging in developing countries for several reasons, including inadequate technology, limited use of data plans, high population density, poverty, mistrust in government, and tendency to ignore or failure to understand the warning messages. Despite the challenges, an individual-level pandemic notification system could provide added benefits by giving an additional route for notification that would be complementary to existing platforms.
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http://dx.doi.org/10.2196/19930DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7279045PMC
June 2020

The impact of SVR from direct-acting antiviral- and interferon-based treatments for HCV on hepatocellular carcinoma risk.

J Viral Hepat 2020 08 17;27(8):781-793. Epub 2020 Apr 17.

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

We evaluated the effect of sustained virologic response (SVR) from direct-acting antiviral (DAA)- and interferon-based treatments on hepatocellular carcinoma (HCC) risk in a large population-based cohort in Canada. We used data from the BC Hepatitis Testers Cohort, which includes ~1.3 million individuals tested for HCV since 1990, linked with healthcare administrative and registry datasets. Patients were followed from the end of HCV treatment to HCC, death or 31 December 2016. We assessed HCC risk among those who did and did not achieve SVR by treatment type using proportional hazard models. Of 12 776 eligible individuals, 3905 received DAAs while 8871 received interferon-based treatments, followed for a median of 1.0 [range: 0.6-2.7] and 7.9 [range: 4.4-17.1] years, respectively. A total of 3613 and 6575 achieved SVR with DAAs- and interferon-based treatments, respectively. Among DAAs-treated patients, HCC incidence rate was 6.9 (95%CI: 4.7-10.1)/1000 person yr (PY) in SVR group (HCC cases: 26) and 38.2 (95%CI: 20.6-71.0) in the no-SVR group (HCC cases: 10, P < .001). Among interferon-treated individuals, HCC incidence rate was 1.8 (95%CI: 1.5-2.2) in the SVR (HCC cases: 99) and 13.9 (95%CI: 12.3-15.8) in the no-SVR group (HCC cases: 239, P < .001). Compared with no-SVR from interferon, SVR from DAA- and interferon-based treatments resulted in significant reduction in HCC risk (adjusted subdistribution hazard ratio (adjSHR) DAA = 0.30, 95%CI: 0.19-0.48 and adjSHR interferon = 0.2, 95%CI: 0.16-0.26). Among those with SVR, treatment with DAAs compared to interferon was not associated with HCC risk (adjSHR = 0.93, 95%CI: 0.51-1.71). In conclusion, similar to interferon era, DAA-related SVR is associated with 70% reduction in HCC risk.
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http://dx.doi.org/10.1111/jvh.13295DOI Listing
August 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

Loss to follow-up: A significant barrier in the treatment cascade with direct-acting therapies.

J Viral Hepat 2020 03 2;27(3):243-260. Epub 2019 Dec 2.

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

Effectiveness of direct-acting antiviral (DAA) therapies could be influenced by patient characteristics such as comorbid conditions, which could lead to premature treatment discontinuation and/or irregular medical follow-ups. Here, we evaluate loss to follow-up and treatment effectiveness of sofosbuvir/ledipasvir ± ribavirin (SOF/LDV ± RBV), ombitasvir/paritaprevir/ritonavir + dasabuvir ± ribavirin (OBV/PTV/r + DSV ± RBV) for hepatitis C virus (HCV) genotype 1 (GT1) and sofosbuvir + ribavirin (SOF + RBV) for genotype 3 (GT3) in British Columbia Canada: The British Columbia Hepatitis Testers Cohort includes data on individuals tested for HCV since 1992, integrated with medical visit, hospitalization and prescription drug data. HCV-positive individuals who initiated DAA regimens, irrespective of treatment completion, for GT1 and GT3 until 31 December, 2017 were included. Factors associated with sustained virological response (SVR) and loss to follow-up were assessed by using multivariable logistic regression models. In total 4477 individuals initiated DAAs. The most common prescribed DAA was SOF/LDV ± RBV with SVR of 95%. The highest SVR of 99.5% was observed among OBV/PTV/r + DSV-treated patients. Overall, 453 (10.1%) individuals were lost to follow-up. Higher loss to follow-up was observed among GT1 patients treated with OBV (17.8%) and GT3 patients (15.7%). The loss to follow-up rate was significantly higher among individuals aged <60 years, those with a history of injection drug use (IDU), on opioid substitution therapy and with cirrhosis. Our findings indicate that loss to follow-up exceeds viral failure in HCV DAA therapy and its rate varies significantly by genotype and treatment regimen. Depending on the aetiology of lost to follow-up, personalized case management for those with medical complications and supporting services among IDU are needed to achieve the full benefits of effective treatments.
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http://dx.doi.org/10.1111/jvh.13228DOI Listing
March 2020

Mapping 123 million neonatal, infant and child deaths between 2000 and 2017.

Authors:
Roy Burstein Nathaniel J Henry Michael L Collison Laurie B Marczak Amber Sligar Stefanie Watson Neal Marquez Mahdieh Abbasalizad-Farhangi Masoumeh Abbasi Foad Abd-Allah Amir Abdoli Mohammad Abdollahi Ibrahim Abdollahpour Rizwan Suliankatchi Abdulkader Michael R M Abrigo Dilaram Acharya Oladimeji M Adebayo Victor Adekanmbi Davoud Adham Mahdi Afshari Mohammad Aghaali Keivan Ahmadi Mehdi Ahmadi Ehsan Ahmadpour Rushdia Ahmed Chalachew Genet Akal Joshua O Akinyemi Fares Alahdab Noore Alam Genet Melak Alamene Kefyalew Addis Alene Mehran Alijanzadeh Cyrus Alinia Vahid Alipour Syed Mohamed Aljunid Mohammed J Almalki Hesham M Al-Mekhlafi Khalid Altirkawi Nelson Alvis-Guzman Adeladza Kofi Amegah Saeed Amini Arianna Maever Loreche Amit Zohreh Anbari Sofia Androudi Mina Anjomshoa Fereshteh Ansari Carl Abelardo T Antonio Jalal Arabloo Zohreh Arefi Olatunde Aremu Bahram Armoon Amit Arora Al Artaman Anvar Asadi Mehran Asadi-Aliabadi Amir Ashraf-Ganjouei Reza Assadi Bahar Ataeinia Sachin R Atre Beatriz Paulina Ayala Quintanilla Martin Amogre Ayanore Samad Azari Ebrahim Babaee Arefeh Babazadeh Alaa Badawi Soghra Bagheri Mojtaba Bagherzadeh Nafiseh Baheiraei Abbas Balouchi Aleksandra Barac Quique Bassat Bernhard T Baune Mohsen Bayati Neeraj Bedi Ettore Beghi Masoud Behzadifar Meysam Behzadifar Yared Belete Belay Brent Bell Michelle L Bell Dessalegn Ajema Berbada Robert S Bernstein Natalia V Bhattacharjee Suraj Bhattarai Zulfiqar A Bhutta Ali Bijani Somayeh Bohlouli Nicholas J K Breitborde Gabrielle Britton Annie J Browne Sharath Burugina Nagaraja Reinhard Busse Zahid A Butt Josip Car Rosario Cárdenas Carlos A Castañeda-Orjuela Ester Cerin Wagaye Fentahun Chanie Pranab Chatterjee Dinh-Toi Chu Cyrus Cooper Vera M Costa Koustuv Dalal Lalit Dandona Rakhi Dandona Farah Daoud Ahmad Daryani Rajat Das Gupta Ian Davis Nicole Davis Weaver Dragos Virgil Davitoiu Jan-Walter De Neve Feleke Mekonnen Demeke Gebre Teklemariam Demoz Kebede Deribe Rupak Desai Aniruddha Deshpande Hanna Demelash 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R Nielsen Dina Nur Anggraini Ningrum Yirga Legesse Nirayo Molly R Nixon Chukwudi A Nnaji Marzieh Nojomi Mehdi Noroozi Shirin Nosratnejad Jean Jacques Noubiap Soraya Nouraei Motlagh Richard Ofori-Asenso Felix Akpojene Ogbo Kelechi E Oladimeji Andrew T Olagunju Meysam Olfatifar Solomon Olum Bolajoko Olubukunola Olusanya Mojisola Morenike Oluwasanu Obinna E Onwujekwe Eyal Oren Doris D V Ortega-Altamirano Alberto Ortiz Osayomwanbo Osarenotor Frank B Osei Aaron E Osgood-Zimmerman Stanislav S Otstavnov Mayowa Ojo Owolabi Mahesh P A Abdol Sattar Pagheh Smita Pakhale Songhomitra Panda-Jonas Animika Pandey Eun-Kee Park Hadi Parsian Tahereh Pashaei Sangram Kishor Patel Veincent Christian Filipino Pepito Alexandre Pereira Samantha Perkins Brandon V Pickering Thomas Pilgrim Majid Pirestani Bakhtiar Piroozi Meghdad Pirsaheb Oleguer Plana-Ripoll Hadi Pourjafar Parul Puri Mostafa Qorbani Hedley Quintana Mohammad Rabiee Navid Rabiee Amir Radfar Alireza Rafiei Fakher Rahim Zohreh Rahimi Vafa Rahimi-Movaghar Shadi Rahimzadeh Fatemeh Rajati Sree Bhushan Raju Azra Ramezankhani Chhabi Lal Ranabhat Davide Rasella Vahid Rashedi Lal Rawal Robert C Reiner Andre M N Renzaho Satar Rezaei Aziz Rezapour Seyed Mohammad Riahi Ana Isabel Ribeiro Leonardo Roever Elias Merdassa Roro Max Roser Gholamreza Roshandel Daem Roshani Ali Rostami Enrico Rubagotti Salvatore Rubino Siamak Sabour Nafis Sadat Ehsan Sadeghi Reza Saeedi Yahya Safari Roya Safari-Faramani Mahdi Safdarian Amirhossein Sahebkar Mohammad Reza Salahshoor Nasir Salam Payman Salamati Farkhonde Salehi Saleh Salehi Zahabi Yahya Salimi Hamideh Salimzadeh Joshua A Salomon Evanson Zondani Sambala Abdallah M Samy Milena M Santric Milicevic Bruno Piassi Sao Jose Sivan Yegnanarayana Iyer Saraswathy Rodrigo Sarmiento-Suárez Benn Sartorius Brijesh Sathian Sonia Saxena Alyssa N Sbarra Lauren E Schaeffer David C Schwebel Sadaf G Sepanlou Seyedmojtaba Seyedmousavi Faramarz Shaahmadi Masood Ali Shaikh Mehran Shams-Beyranvand Amir Shamshirian Morteza Shamsizadeh Kiomars Sharafi Mehdi Sharif Mahdi Sharif-Alhoseini Hamid Sharifi Jayendra Sharma Rajesh Sharma Aziz Sheikh Chloe Shields Mika Shigematsu Rahman Shiri Ivy Shiue Kerem Shuval Tariq J Siddiqi João Pedro Silva Jasvinder A Singh Dhirendra Narain Sinha Malede Mequanent Sisay Solomon Sisay Karen Sliwa David L Smith Ranjani Somayaji Moslem Soofi Joan B Soriano Chandrashekhar T Sreeramareddy Agus Sudaryanto Mu'awiyyah Babale Sufiyan Bryan L Sykes P N Sylaja Rafael Tabarés-Seisdedos Karen M Tabb Takahiro Tabuchi Nuno Taveira Mohamad-Hani Temsah Abdullah Sulieman Terkawi Zemenu Tadesse Tessema Kavumpurathu Raman Thankappan Sathish Thirunavukkarasu Quyen G To Marcos Roberto Tovani-Palone Bach Xuan Tran Khanh Bao Tran Irfan Ullah Muhammad Shariq Usman Olalekan A Uthman Amir Vahedian-Azimi Pascual R Valdez Job F M van Boven Tommi Juhani Vasankari Yasser Vasseghian Yousef Veisani Narayanaswamy Venketasubramanian Francesco S Violante Sergey Konstantinovitch Vladimirov Vasily Vlassov Theo Vos Giang Thu Vu Isidora S Vujcic Yasir Waheed Jon Wakefield Haidong Wang Yafeng Wang Yuan-Pang Wang Joseph L Ward Robert G Weintraub Kidu Gidey Weldegwergs Girmay Teklay Weldesamuel Ronny Westerman Charles Shey Wiysonge Dawit Zewdu Wondafrash Lauren Woyczynski Ai-Min Wu Gelin Xu Abbas Yadegar Tomohide Yamada Vahid Yazdi-Feyzabadi Christopher Sabo Yilgwan Paul Yip Naohiro Yonemoto Javad Yoosefi Lebni Mustafa Z Younis Mahmoud Yousefifard Hebat-Allah Salah A Yousof Chuanhua Yu Hasan Yusefzadeh Erfan Zabeh Telma Zahirian Moghadam Sojib Bin Zaman Mohammad Zamani Hamed Zandian Alireza Zangeneh Taddese Alemu Zerfu Yunquan Zhang Arash Ziapour Sanjay Zodpey Christopher J L Murray Simon I Hay

Nature 2019 10 16;574(7778):353-358. Epub 2019 Oct 16.

Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA.

Since 2000, many countries have achieved considerable success in improving child survival, but localized progress remains unclear. To inform efforts towards United Nations Sustainable Development Goal 3.2-to end preventable child deaths by 2030-we need consistently estimated data at the subnational level regarding child mortality rates and trends. Here we quantified, for the period 2000-2017, the subnational variation in mortality rates and number of deaths of neonates, infants and children under 5 years of age within 99 low- and middle-income countries using a geostatistical survival model. We estimated that 32% of children under 5 in these countries lived in districts that had attained rates of 25 or fewer child deaths per 1,000 live births by 2017, and that 58% of child deaths between 2000 and 2017 in these countries could have been averted in the absence of geographical inequality. This study enables the identification of high-mortality clusters, patterns of progress and geographical inequalities to inform appropriate investments and implementations that will help to improve the health of all populations.
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http://dx.doi.org/10.1038/s41586-019-1545-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6800389PMC
October 2019

Global, Regional, and National Cancer Incidence, Mortality, Years of Life Lost, Years Lived With Disability, and Disability-Adjusted Life-Years for 29 Cancer Groups, 1990 to 2017: A Systematic Analysis for the Global Burden of Disease Study.

Authors:
Christina Fitzmaurice Degu Abate Naghmeh Abbasi Hedayat Abbastabar Foad Abd-Allah Omar Abdel-Rahman Ahmed Abdelalim Amir Abdoli Ibrahim Abdollahpour Abdishakur S M Abdulle Nebiyu Dereje Abebe Haftom Niguse Abraha Laith Jamal Abu-Raddad Ahmed Abualhasan Isaac Akinkunmi Adedeji Shailesh M Advani Mohsen Afarideh Mahdi Afshari Mohammad Aghaali Dominic Agius Sutapa Agrawal Ayat Ahmadi Elham Ahmadian Ehsan Ahmadpour Muktar Beshir Ahmed Mohammad Esmaeil Akbari Tomi Akinyemiju Ziyad Al-Aly Assim M AlAbdulKader Fares Alahdab Tahiya Alam Genet Melak Alamene Birhan Tamene T Alemnew Kefyalew Addis Alene Cyrus Alinia Vahid Alipour Syed Mohamed Aljunid Fatemeh Allah Bakeshei Majid Abdulrahman Hamad Almadi Amir Almasi-Hashiani Ubai Alsharif Shirina Alsowaidi Nelson Alvis-Guzman Erfan Amini Saeed Amini Yaw Ampem Amoako Zohreh Anbari Nahla Hamed Anber Catalina Liliana Andrei Mina Anjomshoa Fereshteh Ansari Ansariadi Ansariadi Seth Christopher Yaw Appiah Morteza Arab-Zozani Jalal Arabloo Zohreh Arefi Olatunde Aremu Habtamu Abera Areri Al Artaman Hamid Asayesh Ephrem Tsegay Asfaw Alebachew Fasil Ashagre Reza Assadi Bahar Ataeinia Hagos Tasew Atalay Zerihun Ataro Suleman Atique Marcel Ausloos Leticia Avila-Burgos Euripide F G A Avokpaho Ashish Awasthi Nefsu Awoke Beatriz Paulina Ayala Quintanilla Martin Amogre Ayanore Henok Tadesse Ayele Ebrahim Babaee Umar Bacha Alaa Badawi Mojtaba Bagherzadeh Eleni Bagli Senthilkumar Balakrishnan Abbas Balouchi Till Winfried Bärnighausen Robert J Battista Masoud Behzadifar Meysam Behzadifar Bayu Begashaw Bekele Yared Belete Belay Yaschilal Muche Belayneh Kathleen Kim Sachiko Berfield Adugnaw Berhane Eduardo Bernabe Mircea Beuran Nickhill Bhakta Krittika Bhattacharyya Belete Biadgo Ali Bijani Muhammad Shahdaat Bin Sayeed Charles Birungi Catherine Bisignano Helen Bitew Tone Bjørge Archie Bleyer Kassawmar Angaw Bogale Hunduma Amensisa Bojia Antonio M Borzì Cristina Bosetti Ibrahim R Bou-Orm Hermann Brenner Jerry D Brewer Andrey Nikolaevich Briko Nikolay Ivanovich Briko Maria Teresa Bustamante-Teixeira Zahid A Butt Giulia Carreras Juan J Carrero Félix Carvalho Clara Castro Franz Castro Ferrán Catalá-López Ester Cerin Yazan Chaiah Wagaye Fentahun Chanie Vijay Kumar Chattu Pankaj Chaturvedi Neelima Singh Chauhan Mohammad Chehrazi Peggy Pei-Chia Chiang Tesfaye Yitna Chichiabellu Onyema Greg Chido-Amajuoyi Odgerel Chimed-Ochir Jee-Young J Choi Devasahayam J Christopher Dinh-Toi Chu Maria-Magdalena Constantin Vera M Costa Emanuele Crocetti Christopher Stephen Crowe Maria Paula Curado Saad M A Dahlawi Giovanni Damiani Amira Hamed Darwish Ahmad Daryani José das Neves Feleke Mekonnen Demeke Asmamaw Bizuneh Demis Birhanu Wondimeneh Demissie Gebre Teklemariam Demoz Edgar Denova-Gutiérrez Afshin Derakhshani Kalkidan Solomon Deribe Rupak Desai Beruk Berhanu Desalegn Melaku Desta Subhojit Dey Samath Dhamminda Dharmaratne Meghnath Dhimal Daniel Diaz Mesfin Tadese Tadese Dinberu Shirin Djalalinia David Teye Doku Thomas M Drake Manisha Dubey Eleonora Dubljanin Eyasu Ejeta Duken Hedyeh Ebrahimi Andem Effiong Aziz Eftekhari Iman El Sayed Maysaa El Sayed Zaki Shaimaa I El-Jaafary Ziad El-Khatib Demelash Abewa Elemineh Hajer Elkout Richard G Ellenbogen Aisha Elsharkawy Mohammad Hassan Emamian Daniel Adane Endalew Aman Yesuf Endries Babak Eshrati Ibtihal Fadhil Vahid Fallah Omrani Mahbobeh Faramarzi Mahdieh Abbasalizad Farhangi Andrea Farioli Farshad Farzadfar Netsanet Fentahun Eduarda Fernandes Garumma Tolu Feyissa Irina Filip Florian Fischer James L Fisher Lisa M Force Masoud Foroutan Marisa Freitas Takeshi Fukumoto Neal D Futran Silvano Gallus Fortune Gbetoho Gankpe Reta Tsegaye Gayesa Tsegaye Tewelde Gebrehiwot Gebreamlak Gebremedhn Gebremeskel Getnet Azeze Gedefaw Belayneh K Gelaw Birhanu Geta Sefonias Getachew Kebede Embaye Gezae Mansour Ghafourifard Alireza Ghajar Ahmad Ghashghaee Asadollah Gholamian Paramjit Singh Gill Themba T G Ginindza Alem Girmay Muluken Gizaw Ricardo Santiago Gomez Sameer Vali Gopalani Giuseppe Gorini Bárbara Niegia Garcia Goulart Ayman Grada Maximiliano Ribeiro Guerra Andre Luiz Sena Guimaraes Prakash C Gupta Rahul Gupta Kishor Hadkhale Arvin Haj-Mirzaian Arya Haj-Mirzaian Randah R Hamadeh Samer Hamidi Lolemo Kelbiso Hanfore Josep Maria Haro Milad Hasankhani Amir Hasanzadeh Hamid Yimam Hassen Roderick J Hay Simon I Hay Andualem Henok Nathaniel J Henry Claudiu Herteliu Hagos D Hidru Chi Linh Hoang Michael K Hole Praveen Hoogar Nobuyuki Horita H Dean Hosgood Mostafa Hosseini Mehdi Hosseinzadeh Mihaela Hostiuc Sorin Hostiuc Mowafa Househ Mohammedaman Mama Hussen Bogdan Ileanu Milena D Ilic Kaire Innos Seyed Sina Naghibi Irvani Kufre Robert Iseh Sheikh Mohammed Shariful Islam Farhad Islami Nader Jafari Balalami Morteza Jafarinia Leila Jahangiry Mohammad Ali Jahani Nader Jahanmehr Mihajlo Jakovljevic Spencer L James Mehdi Javanbakht Sudha Jayaraman Sun Ha Jee Ensiyeh Jenabi Ravi Prakash Jha Jost B Jonas Jitendra Jonnagaddala Tamas Joo Suresh Banayya Jungari Mikk Jürisson Ali Kabir Farin Kamangar André Karch Narges Karimi Ansar Karimian Amir Kasaeian Gebremicheal Gebreslassie Kasahun Belete Kassa Tesfaye Dessale Kassa Mesfin Wudu Kassaw Anil Kaul Peter Njenga Keiyoro Abraham Getachew Kelbore Amene Abebe Kerbo Yousef Saleh Khader Maryam Khalilarjmandi Ejaz Ahmad Khan Gulfaraz Khan Young-Ho Khang Khaled Khatab Amir Khater Maryam Khayamzadeh Maryam Khazaee-Pool Salman Khazaei Abdullah T Khoja Mohammad Hossein Khosravi Jagdish Khubchandani Neda Kianipour Daniel Kim Yun Jin Kim Adnan Kisa Sezer Kisa Katarzyna Kissimova-Skarbek Hamidreza Komaki Ai Koyanagi Kristopher J Krohn Burcu Kucuk Bicer Nuworza Kugbey Vivek Kumar Desmond Kuupiel Carlo La Vecchia Deepesh P Lad Eyasu Alem Lake Ayenew Molla Lakew Dharmesh Kumar Lal Faris Hasan Lami Qing Lan Savita Lasrado Paolo Lauriola Jeffrey V Lazarus James Leigh Cheru Tesema Leshargie Yu Liao Miteku Andualem Limenih Stefan Listl Alan D Lopez Platon D Lopukhov Raimundas Lunevicius Mohammed Madadin Sameh Magdeldin Hassan Magdy Abd El Razek Azeem Majeed Afshin Maleki Reza Malekzadeh Ali Manafi Navid Manafi Wondimu Ayele Manamo Morteza Mansourian Mohammad Ali Mansournia Lorenzo Giovanni Mantovani Saman Maroufizadeh Santi Martini S Martini Tivani Phosa Mashamba-Thompson Benjamin Ballard Massenburg Motswadi Titus Maswabi Manu Raj Mathur Colm McAlinden Martin McKee Hailemariam Abiy Alemu Meheretu Ravi Mehrotra Varshil Mehta Toni Meier Yohannes A Melaku Gebrekiros Gebremichael Meles Hagazi Gebre Meles Addisu Melese Mulugeta Melku Peter T N Memiah Walter Mendoza Ritesh G Menezes Shahin Merat Tuomo J Meretoja Tomislav Mestrovic Bartosz Miazgowski Tomasz Miazgowski Kebadnew Mulatu M Mihretie Ted R Miller Edward J Mills Seyed Mostafa Mir Hamed Mirzaei Hamid Reza Mirzaei Rashmi Mishra Babak Moazen Dara K Mohammad Karzan Abdulmuhsin Mohammad Yousef Mohammad Aso Mohammad Darwesh Abolfazl Mohammadbeigi Hiwa Mohammadi Moslem Mohammadi Mahdi Mohammadian Abdollah Mohammadian-Hafshejani Milad Mohammadoo-Khorasani Reza Mohammadpourhodki Ammas Siraj Mohammed Jemal Abdu Mohammed Shafiu Mohammed Farnam Mohebi Ali H Mokdad Lorenzo Monasta Yoshan Moodley Mahmood Moosazadeh Maryam Moossavi Ghobad Moradi Mohammad Moradi-Joo Maziar Moradi-Lakeh Farhad Moradpour Lidia Morawska Joana Morgado-da-Costa Naho Morisaki Shane Douglas Morrison Abbas Mosapour Seyyed Meysam Mousavi Achenef Asmamaw Muche Oumer Sada S Muhammed Jonah Musa Ashraf F Nabhan Mehdi Naderi Ahamarshan Jayaraman Nagarajan Gabriele Nagel Azin Nahvijou Gurudatta Naik Farid Najafi Luigi Naldi Hae Sung Nam Naser Nasiri Javad Nazari Ionut Negoi Subas Neupane Polly A Newcomb Haruna Asura Nggada Josephine W Ngunjiri Cuong Tat Nguyen Leila Nikniaz Dina Nur Anggraini Ningrum Yirga Legesse Nirayo Molly R Nixon Chukwudi A Nnaji Marzieh Nojomi Shirin Nosratnejad Malihe Nourollahpour Shiadeh Mohammed Suleiman Obsa Richard Ofori-Asenso Felix Akpojene Ogbo In-Hwan Oh Andrew T Olagunju Tinuke O Olagunju Mojisola Morenike Oluwasanu Abidemi E Omonisi Obinna E Onwujekwe Anu Mary Oommen Eyal Oren Doris D V Ortega-Altamirano Erika Ota Stanislav S Otstavnov Mayowa Ojo Owolabi Mahesh P A Jagadish Rao Padubidri Smita Pakhale Amir H Pakpour Adrian Pana Eun-Kee Park Hadi Parsian Tahereh Pashaei Shanti Patel Snehal T Patil Alyssa Pennini David M Pereira Cristiano Piccinelli Julian David Pillay Majid Pirestani Farhad Pishgar Maarten J Postma Hadi Pourjafar Farshad Pourmalek Akram Pourshams Swayam Prakash Narayan Prasad Mostafa Qorbani Mohammad Rabiee Navid Rabiee Amir Radfar Alireza Rafiei Fakher Rahim Mahdi Rahimi Muhammad Aziz Rahman Fatemeh Rajati Saleem M Rana Samira Raoofi Goura Kishor Rath David Laith Rawaf Salman Rawaf Robert C Reiner Andre M N Renzaho Nima Rezaei Aziz Rezapour Ana Isabel Ribeiro Daniela Ribeiro Luca Ronfani Elias Merdassa Roro Gholamreza Roshandel Ali Rostami Ragy Safwat Saad Parisa Sabbagh Siamak Sabour Basema Saddik Saeid Safiri Amirhossein Sahebkar Mohammad Reza Salahshoor Farkhonde Salehi Hosni Salem Marwa Rashad Salem Hamideh Salimzadeh Joshua A Salomon Abdallah M Samy Juan Sanabria Milena M Santric Milicevic Benn Sartorius Arash Sarveazad Brijesh Sathian Maheswar Satpathy Miloje Savic Monika Sawhney Mehdi Sayyah Ione J C Schneider Ben Schöttker Mario Sekerija Sadaf G Sepanlou Masood Sepehrimanesh Seyedmojtaba Seyedmousavi Faramarz Shaahmadi Hosein Shabaninejad Mohammad Shahbaz Masood Ali Shaikh Amir Shamshirian Morteza Shamsizadeh Heidar Sharafi Zeinab Sharafi Mehdi Sharif Ali Sharifi Hamid Sharifi Rajesh Sharma Aziz Sheikh Reza Shirkoohi Sharvari Rahul Shukla Si Si Soraya Siabani Diego Augusto Santos Silva Dayane Gabriele Alves Silveira Ambrish Singh Jasvinder A Singh Solomon Sisay Freddy Sitas Eugène Sobngwi Moslem Soofi Joan B Soriano Vasiliki Stathopoulou Mu'awiyyah Babale Sufiyan Rafael Tabarés-Seisdedos Takahiro Tabuchi Ken Takahashi Omid Reza Tamtaji Mohammed Rasoul Tarawneh Segen Gebremeskel Tassew Parvaneh Taymoori Arash Tehrani-Banihashemi Mohamad-Hani Temsah Omar Temsah Berhe Etsay Tesfay Fisaha Haile Tesfay Manaye Yihune Teshale Gizachew Assefa Tessema Subash Thapa Kenean Getaneh Tlaye Roman Topor-Madry Marcos Roberto Tovani-Palone Eugenio Traini Bach Xuan Tran Khanh Bao Tran Afewerki Gebremeskel Tsadik Irfan Ullah Olalekan A Uthman Marco Vacante Maryam Vaezi Patricia Varona Pérez Yousef Veisani Simone Vidale Francesco S Violante Vasily Vlassov Stein Emil Vollset Theo Vos Kia Vosoughi Giang Thu Vu Isidora S Vujcic Henry Wabinga Tesfahun Mulatu Wachamo Fasil Shiferaw Wagnew Yasir Waheed Fitsum Weldegebreal Girmay Teklay Weldesamuel Tissa Wijeratne Dawit Zewdu Wondafrash Tewodros Eshete Wonde Adam Belay Wondmieneh Hailemariam Mekonnen Workie Rajaram Yadav Abbas Yadegar Ali Yadollahpour Mehdi Yaseri Vahid Yazdi-Feyzabadi Alex Yeshaneh Mohammed Ahmed Yimam Ebrahim M Yimer Engida Yisma Naohiro Yonemoto Mustafa Z Younis Bahman Yousefi Mahmoud Yousefifard Chuanhua Yu Erfan Zabeh Vesna Zadnik Telma Zahirian Moghadam Zoubida Zaidi Mohammad Zamani Hamed Zandian Alireza Zangeneh Leila Zaki Kazem Zendehdel Zerihun Menlkalew Zenebe Taye Abuhay Zewale Arash Ziapour Sanjay Zodpey Christopher J L Murray

JAMA Oncol 2019 12;5(12):1749-1768

Institute for Health Metrics and Evaluation, University of Washington, Seattle.

Importance: Cancer and other noncommunicable diseases (NCDs) are now widely recognized as a threat to global development. The latest United Nations high-level meeting on NCDs reaffirmed this observation and also highlighted the slow progress in meeting the 2011 Political Declaration on the Prevention and Control of Noncommunicable Diseases and the third Sustainable Development Goal. Lack of situational analyses, priority setting, and budgeting have been identified as major obstacles in achieving these goals. All of these have in common that they require information on the local cancer epidemiology. The Global Burden of Disease (GBD) study is uniquely poised to provide these crucial data.

Objective: To describe cancer burden for 29 cancer groups in 195 countries from 1990 through 2017 to provide data needed for cancer control planning.

Evidence Review: We used the GBD study estimation methods to describe cancer incidence, mortality, years lived with disability, years of life lost, and disability-adjusted life-years (DALYs). Results are presented at the national level as well as by Socio-demographic Index (SDI), a composite indicator of income, educational attainment, and total fertility rate. We also analyzed the influence of the epidemiological vs the demographic transition on cancer incidence.

Findings: In 2017, there were 24.5 million incident cancer cases worldwide (16.8 million without nonmelanoma skin cancer [NMSC]) and 9.6 million cancer deaths. The majority of cancer DALYs came from years of life lost (97%), and only 3% came from years lived with disability. The odds of developing cancer were the lowest in the low SDI quintile (1 in 7) and the highest in the high SDI quintile (1 in 2) for both sexes. In 2017, the most common incident cancers in men were NMSC (4.3 million incident cases); tracheal, bronchus, and lung (TBL) cancer (1.5 million incident cases); and prostate cancer (1.3 million incident cases). The most common causes of cancer deaths and DALYs for men were TBL cancer (1.3 million deaths and 28.4 million DALYs), liver cancer (572 000 deaths and 15.2 million DALYs), and stomach cancer (542 000 deaths and 12.2 million DALYs). For women in 2017, the most common incident cancers were NMSC (3.3 million incident cases), breast cancer (1.9 million incident cases), and colorectal cancer (819 000 incident cases). The leading causes of cancer deaths and DALYs for women were breast cancer (601 000 deaths and 17.4 million DALYs), TBL cancer (596 000 deaths and 12.6 million DALYs), and colorectal cancer (414 000 deaths and 8.3 million DALYs).

Conclusions And Relevance: The national epidemiological profiles of cancer burden in the GBD study show large heterogeneities, which are a reflection of different exposures to risk factors, economic settings, lifestyles, and access to care and screening. The GBD study can be used by policy makers and other stakeholders to develop and improve national and local cancer control in order to achieve the global targets and improve equity in cancer care.
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http://dx.doi.org/10.1001/jamaoncol.2019.2996DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6777271PMC
December 2019

What is killing people with hepatitis C virus infection? Analysis of a population-based cohort in Canada.

Int J Drug Policy 2019 10 20;72:114-122. Epub 2019 Jun 20.

Clinical Prevention Services, British Columbia Centre for Disease Control, Vancouver, BC, Canada; School of Population and Public Health, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada.

Background: Persons with hepatitis C virus (HCV) infection are at risk of mortality from both chronic liver disease and HCV acquisition risk activities. We compared causes of death among HCV positive and negative individuals to characterize contributions of acquisition risks and viral sequelae.

Methods: The British Columbia (BC) Hepatitis Testers Cohort (BC-HTC) includes all individuals tested for HCV or reported as a HCV case since 1992, linked to health administrative data. ICD-10 codes were used to classify deaths as: 1) liver-related (LR); 2) HCV acquisition risk-related (AR); and 3) other causes. Mortality proportions and trends were assessed among HCV positive and negative individuals overall and by birth cohort (born <1945, 1945-64 and ≥1965).

Results: As of December 31, 2018, of 1,300,204 HCV-tested individuals, 20,049 (27.5%) HCV positive and 132,999 (10.2%) HCV negative individuals had died (median age at death: 56.4 vs. 74.5 years, respectively). HCV positive individuals were more likely than negatives to die from both AR (24.7%/4.2%) and LR (23.4%/6.2%) causes. Deaths among older HCV positive individuals were more likely to be LR while younger individuals were more likely AR: 1) birth cohort <1945 (25.3%/2.7%); 2) 1945-64 (26.5%/23.7%) and ≥1965 (7.7%/59.9%). Among HCV positives, LR mortality increased from 1992 to 2014, then declined sharply, coinciding with the introduction and uptake of direct-acting antiviral drugs. AR mortality increased from 1992 to 2000, declined slowly until 2013, then rapidly increased, coinciding with the recent surge in opioid overdose deaths.

Conclusions: Curative HCV treatments reduce LR mortality, but typically will not impact AR mortality. This will need to be addressed if the World Health Organization 2030 HCV mortality reduction goals are to be achieved.
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http://dx.doi.org/10.1016/j.drugpo.2019.06.003DOI Listing
October 2019

Syndemic Characterization of HCV, HBV, and HIV Co-infections in a Large Population Based Cohort Study.

EClinicalMedicine 2018 Oct-Nov;4-5:99-108. Epub 2018 Nov 5.

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

Background: Limited data are available on HBV, HCV, and HIV co-infections and triple infection. We characterized co-occurrence of HIV, HBV, and HCV infections at the population level in British Columbia (BC) to identify patterns of predisposing factors unique to co-infection subgroups.

Methods: We analyzed data from the BC Hepatitis Testers Cohort, which includes all individuals tested for HCV or HIV in BC between 1992 and 2013, or included in provincial public health registries of HIV, HCV, HBV, and active tuberculosis. Individuals were classified as negative, mono-, and co-infection groups based on HIV, HBV, and HCV status. We evaluated associations between risk factors (injection drug use, sexual orientation etc.) and co-infection groups using multivariate multinomial logistic regression.

Findings: Of a total of 1,376,989 individuals included in the analysis, 1,276,290 were negative and 100,699 were positive for HIV, HBV, and/or HCV. Most cases (91,399, 90.8%) were mono-infected, while 3991 (4.0%) had HBV/HCV, 670 HBV/HIV (0.7%), 3459 HCV/HIV (3.4%), and 1180 HBV/HCV/HIV (1.2%) co-infection. Risk factor and demographic distribution varied across co-infection categories. MSM classification was associated with higher odds of all HIV co-infection groups, particularly HBV/HIV (OR 6.8; 95% CI: 5.6, 8.27), while injection drug use was most strongly associated with triple infection (OR 64.19; 95% CI: 55.11, 74.77) and HIV/HCV (OR 23.23; 95% CI: 21.32, 25.31).

Interpretation: Syndemics of substance use, sexual practices, mental illness, socioeconomic marginalization, and co-infections differ among population groups, highlighting avenues for optimal composition and context for health services to meet each population's unique needs.

Funding: BC Centre for Disease Control and Canadian Institutes of Health Research.
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http://dx.doi.org/10.1016/j.eclinm.2018.10.006DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6537523PMC
November 2018

Effectiveness of Ledipasvir/Sofosbuvir and Sofosbuvir/Velpatasvir in People Who Inject Drugs and/or Those in Opioid Agonist Therapy.

Hepatol Commun 2019 Apr 10;3(4):478-492. Epub 2019 Jan 10.

British Columbia Centre for Disease Control Vancouver Canada.

We evaluated the effectiveness of ledipasvir/sofosbuvir (LDV/SOF) in treating hepatitis C virus (HCV) genotype 1 and SOF/velpatasvir (SOF/VEL) for all genotypes among people who inject drugs (PWID) and those not injecting drugs and who were on or off opioid agonist therapy (OAT). Study participants comprised a population-based cohort in British Columbia, Canada. The British Columbia Hepatitis Testers Cohort includes data on individuals tested for HCV from 1990 to 2016 that are integrated with medical visits, hospitalization, and prescription drug data. We classified study participants as off OAT/recent injection drug use (off-OAT/RIDU), off OAT/past IDU (off-OAT/PIDU), off OAT/no IDU (off-OAT/NIDU), on OAT/IDU (on-OAT/IDU), and on OAT/no IDU (on-OAT/NIDU). We assessed sustained virologic response (SVR) 10 weeks after HCV treatment among study groups treated with LDV/SOF or SOF/VEL until January 13, 2018. Analysis included 5,283 eligible participants: 390 off-OAT/RIDU, 598 off-OAT/PIDU, 3,515 off-OAT/NIDU, 609 on-OAT/IDU, and 171 on-OAT/NIDU. The majority were male patients (64%-74%) and aged ≥50 years (58%-85%). The SVRs for off-OAT/RIDU, off-OAT/PIDU, off-OAT/NIDU, on-OAT/IDU, and on-OAT/NIDU were 91% (355/390), 95% (570/598), 96% (3,360/3,515), 93% (567/609), and 95% (163/171), respectively. Among those with no SVR, 14 individuals died while on treatment or before SVR assessment, including 4 from illicit drug overdose. In the overall multivariable model, off-OAT/RIDU, on-OAT/IDU, male sex, cirrhosis, treatment duration <8 weeks, treatment duration 8 weeks, and treatment with SOF/VEL were associated with not achieving SVR. In this large real-world cohort, PWID and/or those on OAT achieved high SVRs, although slightly lower than people not injecting drugs. This finding also highlights the need for additional measures to prevent loss to follow-up and overdose-related deaths among PWID.
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http://dx.doi.org/10.1002/hep4.1307DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6442698PMC
April 2019

Applying core theory and spatial analysis to identify hepatitis C virus infection "core areas" in British Columbia, Canada.

J Viral Hepat 2019 03 11;26(3):373-383. Epub 2018 Dec 11.

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

"Core areas" of transmission for bacterial sexually transmitted infections have been identified. However, it is unclear whether core areas apply to viral infections, such as hepatitis C virus (HCV). We used geographic mapping and spatial analysis to identify distinct core areas of HCV infection in British Columbia (BC) using the BC Hepatitis Testers Cohort (BC-HTC), 1990-2013. The BC-HTC includes all BC residents tested for HCV (~1.5 million; 1990-2013). Core HCV infection areas were identified spatially and temporally for five time periods (1990-1993, 1994-1998, 1999-2003, 2004-2008 and 2009-2013) through thematic mapping, Kernel Density Estimation, Hotspot analysis and cluster analysis at the Census dissemination area level in ArcGIS and SatScan. HCV infection core areas were consistently identified. HCV core areas expanded from the downtown of major cities in different regions of BC (Metro Vancouver, Vancouver Island, and Northern BC; 1990-1998), to smaller cities in Metro Vancouver and Interior BC (2000 onwards). Statistically significant clusters, or hotspots, were also observed for downtown Vancouver, Northern BC (Prince George) and Vancouver Island from 1990 to 2008 with expansion to other urban areas in Metro Vancouver from 1990-2013. Statistically significant clusters persisted after adjustment for injection drug use, number of HCV tests, age, sex, material and social deprivation. Persistence of areas with high HCV diagnoses rates in Vancouver and Prince George supports the theory of core areas of HCV transmission. Identification of core areas can inform prevention, care and treatment programme interventions and evaluate their impact over time.
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http://dx.doi.org/10.1111/jvh.13043DOI Listing
March 2019

Risk of adverse treatment outcomes among new pulmonary TB patients co-infected with diabetes in Pakistan: A prospective cohort study.

PLoS One 2018 8;13(11):e0207148. Epub 2018 Nov 8.

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

Purpose: The escalating burden of diabetes in countries tackling high burden of tuberculosis (TB) has adverse implications for co-infected individuals and National TB control efforts. We aimed to study whether there was a difference in treatment outcome among diabetic and non-diabetic pulmonary TB patients and identify the determinants of treatment outcome among the two groups.

Materials And Methods: This prospective cohort study recruited new patients of pulmonary tuberculosis (PTB) aged 15 years and above who were diagnosed at and registered with Gulab Devi Chest Hospital, Lahore, Pakistan for anti-tuberculosis treatment (ATT). PTB patients were screened for diabetes using random and fasting blood glucose tests. Diabetic and non-diabetic PTB patients were followed up at second, fifth and sixth month of ATT and 6 months after ATT completion to determine treatment outcome. Multivariate logistic regression analysis was conducted to assess association between various factors and treatment outcome.

Results: Of 614 PTB patients, (n = 113 [18%]) were diabetic and (n = 501 [82%]) non-diabetic. Final model showed that diabetics were more likely to experience an unfavorable outcome as compared to non-diabetics (adjusted odds ratio [aOR] = 2.70, 95% Confidence Interval [CI] = 1.30 to 5.59). Other predictors of unfavorable outcome included rural residence (aOR = 1.98, 95% CI = 1.14 to 3.47), body mass index less than 18.50 (aOR = 1.89, 95% CI = 1.03 to 3.47) and being a smoker (aOR = 2.03, 95%CI = 1.04 to 3.94).

Conclusion: Our study shows unfavorable treatment outcome among diabetic PTB patients. Integrated models of care with screening/testing and management for diabetes and TB could improve TB treatment outcomes.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0207148PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6224090PMC
April 2019

Effect of opioid-substitution therapy and mental health counseling on HIV risk among hepatitis C-infected individuals.

Clin Epidemiol 2018 31;10:1127-1145. Epub 2018 Aug 31.

School of Population and Public Health, University of British Columbia, Vancouver, BC,

Background: Understanding differences in HIV incidence among people living with hepatitis C virus (HCV) can help inform strategies to prevent HIV infection. We estimated the time to HIV diagnosis among HCV-positive individuals and evaluated factors that could affect HIV-infection risk in this population.

Patients And Methods: The British Columbia Hepatitis Testers Cohort includes all BC residents (~1.5 million: about a third of all residents) tested for HCV and HIV from 1990 to 2013 and is linked to administrative health care and mortality data. All HCV-positive and HIV-negative individuals were followed to measure time to HIV acquisition (positive test) and identify factors associated with HIV acquisition. Adjusted HRs (aHRs) were estimated using Cox proportional-hazard regression.

Results: Of 36,077 HCV-positive individuals, 2,169 (6%) acquired HIV over 266,883 years of follow-up (overall incidence of 8.1 per 1,000 person years). Overall median (IQR) time to HIV infection was 3.87 (6.06) years. In Cox regression, injection-drug use (aHR 1.47, 95% CI 1.33-1.63), HBV infection (aHR 1.34, 95% CI 1.16-1.55), and being a man who has sex with men (aHR 2.78, 95% CI 2.14-3.61) were associated with higher risk of HIV infection. Opioid-substitution therapy (OST) (aHR 0.59, 95% CI 0.52-0.67) and mental health counseling (aHR 0.48, 95% CI 0.43-0.53) were associated with lower risk of HIV infection.

Conclusion: Injection-drug use, HBV coinfection, and being a man who has sex with men were associated with increased HIV risk and engagement in OST and mental health counseling were associated with reduced HIV risk among HCV-positive individuals. Improving access to OST and mental health services could prevent transmission of HIV and other blood-borne infections, especially in settings where access is limited.
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http://dx.doi.org/10.2147/CLEP.S173449DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6124790PMC
August 2018

Hepatitis C virus reinfection after successful treatment with direct-acting antiviral therapy in a large population-based cohort.

J Hepatol 2018 Nov 22;69(5):1007-1014. Epub 2018 Aug 22.

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

Background & Aims: Direct-acting antiviral therapies (DAA) are an important tool for hepatitis C virus (HCV) elimination. However, reinfection among people who inject drugs (PWID) may hamper elimination targets. Therefore, we estimated HCV reinfection rates among DAA-treated individuals, including PWID.

Methods: We analyzed data from the British Columbia Hepatitis Testers Cohort which included ∼1.7 million individuals screened for HCV in British Columbia, Canada. We followed HCV-infected individuals treated with DAAs who achieved a sustained virologic response (SVR) and had ≥1 subsequent HCV RNA measurement to April 22nd, 2018. Reinfection was defined as a positive RNA measurement after SVR. PWID were identified using a validated algorithm and classified based on recent (<3 years) or former (≥3 years before SVR) use. Crude reinfection rates per 100 person-years (PYs) were calculated. Poisson regression was used to model adjusted incidence rate ratios (IRRs) and 95% CIs.

Results: Of 4,114 individuals who met the inclusion criteria, most were male (n = 2,692, 65%), born before 1965 (n = 3,411, 83%) and were either recent (n = 875, 21%) or former PWID (n = 1,793, 44%). Opioid-agonist therapy (OAT) was received by 19% of PWID. We identified 40 reinfections during 2,767 PYs. Reinfection rates were higher among recent (3.1/100 PYs; IRR 6.7; 95% CI 1.9-23.5) and former PWID (1.4/100 PYs; IRR 3.7; 95% CI 1.1-12.9) than non-PWID (0.3/100 PYs). Among recent PWID, reinfection rates were higher among individuals born after 1975 (10.2/100 PYs) and those co-infected with HIV (5.7/100 PYs). Only one PWID receiving daily OAT developed reinfection.

Conclusions: Population-level reinfection rates remain elevated after DAA therapy among PWID because of ongoing exposure risk. Engagement of PWID in harm-reduction and support services is needed to prevent reinfections.

Lay Summary: Direct-acting antivirals are an effective tool for the treatment of hepatitis C virus, enabling the elimination of the virus. However, some patients who have been successfully treated with direct-acting antivirals are at risk of reinfection. Our findings showed that the risk of reinfection was highest among people with recent injection drug use. Among people who inject drugs, daily use of opioid-agonist therapy was associated with a lower risk of reinfection.
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http://dx.doi.org/10.1016/j.jhep.2018.07.025DOI Listing
November 2018

Estimating the impact of early hepatitis C virus clearance on hepatocellular carcinoma risk.

J Viral Hepat 2018 12 28;25(12):1481-1492. Epub 2018 Aug 28.

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

Although achieving sustained virological response (SVR) through antiviral therapy could reduce the risk of hepatocellular carcinoma (HCC) attributable to hepatitis C virus (HCV) infection, the impact of early viral clearance on HCC is not well defined. In this study, we compared the risk of HCC among individuals who spontaneously cleared HCV (SC), the referent population, with the risk in untreated chronic HCV (UCHC), those achieved SVR, and those who failed interferon-based treatment (TF). The BC Hepatitis Testers Cohort (BC-HTC) includes individuals tested for HCV between 1990-2013, integrated with medical visits, hospitalizations, cancers, prescription drugs and mortality data. This analysis included all HCV-positive patients with at least one valid HCV RNA by PCR on or after HCV diagnosis. Of 46 666 HCV-infected individuals, there were 12 527 (26.8%) SC; 24 794 (53.1%) UCHC; 5355 (11.5%) SVR and 3990 (8.5%) TF. HCC incidence was lowest (0.3/1000 person-years (PY)) in the SC group and highest in the TF group (7.7/1000 PY). In a multivariable model, compared to SC, TF had the highest HCC risk (hazard ratio (HR):14.52, 95% confidence interval (CI): 9.83-21.47), followed by UCHC (HR: 5.85; 95% CI: 4.07-8.41). Earlier treatment-based viral clearance similar to SC could decrease HCC incidence by 69.4% (95% CI: 57.5-78.0), 30% (95% CI: 10.8-45.1) and 77.5% (95% CI: 69.4-83.5) among UCHC, SVR and TF patients, respectively. In conclusion, using SC as a real-world comparator group, it showed that substantial reduction in HCC risk could be achieved with earlier treatment initiation. These analyses should be replicated in patients who have been treated with direct acting antiviral therapies.
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http://dx.doi.org/10.1111/jvh.12977DOI Listing
December 2018

Differing profiles of people diagnosed with acute and chronic hepatitis B virus infection in British Columbia, Canada.

World J Gastroenterol 2018 Mar;24(11):1216-1227

British Columbia Centre for Disease Control, Vancouver BC V5Z4R4, Canada.

Aim: To describe the characteristics of people diagnosed with acute and chronic hepatitis B virus (HBV) infection in British Columbia (BC).

Methods: We used data from the BC Hepatitis Testers Cohort (BC-HTC), which includes all individuals tested for hepatitis C virus (HCV) or human immunodeficiency virus (HIV) or those diagnosed with HBV or active tuberculosis in BC since 1990. These data were integrated with prescription drug, medical visit, hospitalization and mortality data. HBV cases were classified as acute or chronic according to provincial guidelines. We compared characteristics of individuals by HBV infection group (acute, chronic and negative). Factors associated with acute or chronic HBV infection were assessed with multinomial logistic regression models in comparison to the HBV negative group.

Results: 46498 of the 1058056 eligible BC-HTC participants were diagnosed with HBV infection. 4.3% of HBV positive individuals were diagnosed with acute HBV infections while 95.7% had chronic infections. Problematic alcohol use, injection drug use, and HIV or HCV co-infection were more common among individuals diagnosed with acute HBV compared to those with chronic infections and HBV negative individuals. In multivariable multinomial logistic regression models, we observed significant associations between acute or chronic HBV diagnosis and being male, age at HBV diagnosis or birth cohort, South and East Asian ethnicity, HCV or HIV infection, and injection drug use. The odds of acute HBV decreased with increasing age among people who inject drugs, while the opposite was true for chronic HBV. Persons with acute HBV were predominantly White (78%) while those with chronic HBV were mostly East Asian (60%). Relative to Whites, East Asians had 12 times greater odds of being diagnosed with chronic HBV infection. These odds increased with increasing socioeconomic deprivation.

Conclusion: Differences in the profiles of people diagnosed with acute and chronic HBV infection necessitate differentiated screening, prevention, care and treatment programs.
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http://dx.doi.org/10.3748/wjg.v24.i11.1216DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5859224PMC
March 2018

Identifying injection drug use and estimating population size of people who inject drugs using healthcare administrative datasets.

Int J Drug Policy 2018 05 23;55:31-39. Epub 2018 Feb 23.

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

Background: Large linked healthcare administrative datasets could be used to monitor programs providing prevention and treatment services to people who inject drugs (PWID). However, diagnostic codes in administrative datasets do not differentiate non-injection from injection drug use (IDU). We validated algorithms based on diagnostic codes and prescription records representing IDU in administrative datasets against interview-based IDU data.

Methods: The British Columbia Hepatitis Testers Cohort (BC-HTC) includes ∼1.7 million individuals tested for HCV/HIV or reported HBV/HCV/HIV/tuberculosis cases in BC from 1990 to 2015, linked to administrative datasets including physician visit, hospitalization and prescription drug records. IDU, assessed through interviews as part of enhanced surveillance at the time of HIV or HCV/HBV diagnosis from a subset of cases included in the BC-HTC (n = 6559), was used as the gold standard. ICD-9/ICD-10 codes for IDU and injecting-related infections (IRI) were grouped with records of opioid substitution therapy (OST) into multiple IDU algorithms in administrative datasets. We assessed the performance of IDU algorithms through calculation of sensitivity, specificity, positive predictive, and negative predictive values.

Results: Sensitivity was highest (90-94%), and specificity was lowest (42-73%) for algorithms based either on IDU or IRI and drug misuse codes. Algorithms requiring both drug misuse and IRI had lower sensitivity (57-60%) and higher specificity (90-92%). An optimal sensitivity and specificity combination was found with two medical visits or a single hospitalization for injectable drugs with (83%/82%) and without OST (78%/83%), respectively. Based on algorithms that included two medical visits, a single hospitalization or OST records, there were 41,358 (1.2% of 11-65 years individuals in BC) recent PWID in BC based on health encounters during 3- year period (2013-2015).

Conclusion: Algorithms for identifying PWID using diagnostic codes in linked administrative data could be used for tracking the progress of programing aimed at PWID. With population-based datasets, this tool can be used to inform much needed estimates of PWID population size.
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http://dx.doi.org/10.1016/j.drugpo.2018.02.001DOI Listing
May 2018

Establishing a cohort in a developing country: Experiences of the diabetes-tuberculosis treatment outcome cohort study.

J Epidemiol Glob Health 2017 12 24;7(4):249-254. Epub 2017 Aug 24.

Department of Epidemiology & Biostatistics, Health Services Academy, Islamabad, Pakistan; School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada.

Background: Prospective cohort studies are instrumental in generating valid scientific evidence based on identifying temporal associations between cause and effect. Researchers in a developing country like Pakistan seldom undertake cohort studies hence little is known about the challenges encountered while conducting them. We describe the retention rates among tuberculosis patients with and without diabetes, look at factors associated with loss to follow up among the cohort and assess operational factors that contributed to retention of cohort.

Methods: A prospective cohort study was initiated in October 2013 at the Gulab Devi Chest Hospital, Lahore, Pakistan. We recruited 614 new adult cases of pulmonary tuberculosis, whose diabetic status was ascertained by conducting random and fasting blood glucose tests. The cohort was followed up at the 2nd, 5th and 6th month while on anti-tuberculosis therapy (ATT) and 6months after ATT completion to determine treatment outcomes among the two groups i.e. patients with diabetes and patients without diabetes.

Results: The overall retention rate was 81.9% (n=503), with 82.3% (93/113) among patients with diabetes and 81.8% (410/501) among patients without diabetes (p=0.91). Age (p=0.001), area of residence (p=0.029), marital status (p=0.001), educational qualification (p=<0.001) and smoking (p=0.026) were significantly associated with loss to follow up. Respondents were lost to follow up due to inability of research team to contact them as either contact numbers provided were incorrect or switched off (44/111, 39.6%).

Conclusion: We were able to retain 81.9% of PTB patients in the diabetes tuberculosis treatment outcome (DITTO) study for 12months. Retention rates among people with and without diabetes were similar. Older age, rural residence, illiteracy and smoking were associated with loss to follow up. The study employed gender matched data collectors, had a 24-h helpline for patients and sent follow up reminders through telephone calls rather than short messaging service, which might have contributed to retention of cohort.
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http://dx.doi.org/10.1016/j.jegh.2017.08.003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7384568PMC
December 2017

Burden of Diarrhea in the Eastern Mediterranean Region, 1990-2013: Findings from the Global Burden of Disease Study 2013.

Authors:
Ibrahim Khalil Danny V Colombara Mohammad Hossein Forouzanfar Christopher Troeger Farah Daoud Maziar Moradi-Lakeh Charbel El Bcheraoui Puja C Rao Ashkan Afshin Raghid Charara Kalkidan Hassen Abate Mohammed Magdy Abd El Razek Foad Abd-Allah Remon Abu-Elyazeed Aliasghar Ahmad Kiadaliri Ali Shafqat Akanda Nadia Akseer Khurshid Alam Deena Alasfoor Raghib Ali Mohammad A AlMazroa Mahmoud A Alomari Rajaa Mohammad Salem Al-Raddadi Ubai Alsharif Shirina Alsowaidi Khalid A Altirkawi Nelson Alvis-Guzman Walid Ammar Carl Abelardo T Antonio Hamid Asayesh Rana Jawad Asghar Suleman Atique Ashish Awasthi Umar Bacha Alaa Badawi Aleksandra Barac Neeraj Bedi Tolesa Bekele Isabela M Bensenor Balem Demtsu Betsu Zulfiqar Bhutta Aref A Bin Abdulhak Zahid A Butt Hadi Danawi Manisha Dubey Aman Yesuf Endries Imad D A Faghmous Talha Farid Maryam S Farvid Farshad Farzadfar Seyed-Mohammad Fereshtehnejad Florian Fischer Joseph Robert Anderson Fitchett Katherine B Gibney Ibrahim Abdelmageem Mohamed Ginawi Melkamu Dedefo Gishu Harish Chander Gugnani Rahul Gupta Gessessew Bugssa Hailu Randah Ribhi Hamadeh Samer Hamidi Hilda L Harb Mohammad T Hedayati Mohamed Hsairi Abdullatif Husseini Nader Jahanmehr Mehdi Javanbakht Tariku Jibat Jost B Jonas Amir Kasaeian Yousef Saleh Khader Abdur Rahman Khan Ejaz Ahmad Khan Gulfaraz Khan Tawfik Ahmed Muthafer Khoja Yohannes Kinfu Niranjan Kissoon Ai Koyanagi Aparna Lal Asma Abdul Abdul Latif Raimundas Lunevicius Hassan Magdy Abd El Razek Azeem Majeed Reza Malekzadeh Alem Mehari Alemayehu B Mekonnen Yohannes Adama Melaku Ziad A Memish Walter Mendoza Awoke Misganaw Layla Abdalla Ibrahim Mohamed Jean B Nachega Quyen Le Nguyen Muhammad Imran Nisar Emmanuel Kwame Peprah James A Platts-Mills Farshad Pourmalek Mostafa Qorbani Anwar Rafay Vafa Rahimi-Movaghar Sajjad Ur Rahman Rajesh Kumar Rai Saleem M Rana Chhabi L Ranabhat Sowmya R Rao Amany H Refaat Mark Riddle Gholamreza Roshandel George Mugambage Ruhago Muhammad Muhammad Saleh Juan R Sanabria Monika Sawhney Sadaf G Sepanlou Tesfaye Setegn Karen Sliwa Chandrashekhar T Sreeramareddy Bryan L Sykes Mohammad Tavakkoli Bemnet Amare Tedla Abdullah S Terkawi Kingsley Ukwaja Olalekan A Uthman Ronny Westerman Mamo Wubshet Muluken A Yenesew Naohiro Yonemoto Mustafa Z Younis Zoubida Zaidi Maysaa El Sayed Zaki Abdullah A Al Rabeeah Haidong Wang Mohsen Naghavi Theo Vos Alan D Lopez Christopher J L Murray Ali H Mokdad

Am J Trop Med Hyg 2016 Dec 10;95(6):1319-1329. Epub 2016 Oct 10.

Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington.

Diarrheal diseases (DD) are leading causes of disease burden, death, and disability, especially in children in low-income settings. DD can also impact a child's potential livelihood through stunted physical growth, cognitive impairment, and other sequelae. As part of the Global Burden of Disease Study, we estimated DD burden, and the burden attributable to specific risk factors and particular etiologies, in the Eastern Mediterranean Region (EMR) between 1990 and 2013. For both sexes and all ages, we calculated disability-adjusted life years (DALYs), which are the sum of years of life lost and years lived with disability. We estimate that over 125,000 deaths (3.6% of total deaths) were due to DD in the EMR in 2013, with a greater burden of DD in low- and middle-income countries. Diarrhea deaths per 100,000 children under 5 years of age ranged from one (95% uncertainty interval [UI] = 0-1) in Bahrain and Oman to 471 (95% UI = 245-763) in Somalia. The pattern for diarrhea DALYs among those under 5 years of age closely followed that for diarrheal deaths. DALYs per 100,000 ranged from 739 (95% UI = 520-989) in Syria to 40,869 (95% UI = 21,540-65,823) in Somalia. Our results highlighted a highly inequitable burden of DD in EMR, mainly driven by the lack of access to proper resources such as water and sanitation. Our findings will guide preventive and treatment interventions which are based on evidence and which follow the ultimate goal of reducing the DD burden.
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http://dx.doi.org/10.4269/ajtmh.16-0339DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5154365PMC
December 2016

Cohort profile: the diabetes-tuberculosis treatment outcome (DITTO) study in Pakistan.

BMJ Open 2016 12 2;6(12):e012970. Epub 2016 Dec 2.

Department of Epidemiology & Biostatistics, Health Services Academy, Islamabad, Pakistan.

Purpose: Pakistan is faced with an increasing prevalence of diabetes in addition to its existing high burden of tuberculosis (TB). Diabetes has a detrimental effect on treatment outcomes of patients with TB, which may hinder achieving the goals of the End-TB strategy by 2030. We conducted a prospective cohort study to determine difference between treatment outcomes among patients with diabetes and new pulmonary tuberculosis (PTB) and patients without diabetes and new PTB. This would help generate contextual and valid scientific evidence from a developing country like Pakistan with its unique interplay of sociocultural, economic and health system factors to inform policy and practice.

Participants: This paper outlines the baseline characteristics of 614 new cases of PTB, aged 15 years and older, which were followed up prospectively at 2nd, 5th and 6th months while on antituberculosis treatment and at 6 months after treatment completion.

Findings To Date: We ascertained patients' diabetic status by conducting random and fasting blood glucose tests and their glycaemic control by determining glycosylated haemoglobin. Treatment outcomes were established using standardised definitions provided by WHO. The assessment of 614 respondents' diabetic status revealed that 113 (18%) were diabetic and 501 (82%) were non-diabetic. A greater proportion of patients with diabetes and PTB were illiterate (n=74/113, 65.5%) as compared to patients without diabetes and PTB (n=249/501, 50%) (p=0.035). More patients with diabetes and PTB gave a history of heart disease (n=14/113, 12%) and hypertension (n=26/113, 23%) as compared to patients without diabetes and PTB (n=2/501, 0.4% (heart disease) and n=13 501, 3% (hypertension)) (p<0.001). Unfavourable treatment outcome was more likely among patients with diabetes and PTB (n=23/93, 25%) as opposed to patients without diabetes and PTB (n=46/410, 11%) (p=0.001).

Future Plans: We are negotiating with the government regarding funding for a further 2-year follow-up of the cohort to ascertain death and relapse in the post-treatment period and also differentiate between re-infection and recurrence among these patients with respect to their diabetic status.
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http://dx.doi.org/10.1136/bmjopen-2016-012970DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5168597PMC
December 2016

Long-term effect of sustained virological response on hepatocellular carcinoma in patients with hepatitis C in Canada.

J Hepatol 2017 03 4;66(3):504-513. Epub 2016 Nov 4.

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

Background & Aims: Evidence is limited on hepatocellular carcinoma (HCC) risk after sustained virological response (SVR) to interferon-based treatment of hepatitis C virus (HCV) infection. We evaluated the effect of SVR on the risk of HCC and estimated its incidence in post-SVR HCV patients from a large population-based Canadian cohort.

Methods: The British Columbia Hepatitis Testers Cohort includes individuals tested for HCV between 1990-2013 linked with data on their medical visits, hospitalizations, cancers, prescription drugs and mortality. Patients receiving interferon-based HCV treatments were followed from the end of treatment to HCC diagnosis, death or December 31, 2012. We examined HCC risk among those who did and did not achieve SVR using multivariable proportional hazard models with the Fine and Gray modification for competing risks.

Results: Of 8147 individuals who received HCV treatment and were eligible for analysis, 4663 (57%) achieved SVR and 3484 (43%) did not. Each group was followed for a median of 5.6years (range: 0.5-12.9) for an HCC incidence rate of 1.1/1000 person-years (PY) among the SVR and 7.2/1000 PY among the no SVR group. The HCC incidence rate was higher among those with cirrhosis (SVR: 6.4, no SVR: 21.0/1000 PY). In the multivariable model, SVR was associated with a lower HCC risk (subdistribution hazard ratio [SHR]=0.20, 95% CI: 0.13-0.3), while cirrhosis (SHR=2.61, 95% CI: 1.68-4.04), age ⩾50years, being male and genotype 3 infection were associated with a higher HCC risk. Among those who achieved SVR, cirrhosis, age ⩾50years and being male were associated with a higher HCC risk.

Conclusion: SVR after interferon-based treatment substantially reduces but does not eliminate HCC risk, which is markedly higher among those with cirrhosis and age ⩾50years at treatment initiation. Treatment of patients at an advanced fibrosis stage with new highly effective drugs will warrant continued surveillance for HCC post-SVR.

Lay Summary: We assessed the effect of successful hepatitis C treatment with older interferon-based treatment on the occurrence of liver cancer (hepatocellular carcinoma) and found that successful treatment prevents liver cancer. However, more people with cirrhosis and older age continued to develop liver cancer after successful treatment. Thus, treatment with new drugs among those with cirrhosis will require continued monitoring for liver cancer.
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http://dx.doi.org/10.1016/j.jhep.2016.10.028DOI Listing
March 2017

The Population Level Cascade of Care for Hepatitis C in British Columbia, Canada: The BC Hepatitis Testers Cohort (BC-HTC).

EBioMedicine 2016 Oct 25;12:189-195. Epub 2016 Aug 25.

British Columbia Centre for Disease Control (BCCDC), 655 West 12th Avenue, Vancouver, BC V5Z 4R4, Canada; Department of Pathology and Laboratory Medicine, University of British Columbia, 2211 Wesbrook Mall, Vancouver, BC V6Z 1Y6, Canada.

Background: Population-level monitoring of hepatitis C virus (HCV) infected people across the cascade of care identifies gaps in access and engagement in care and treatment. We characterized a population-level cascade of care for HCV in British Columbia (BC), Canada and identified factors associated with leakage at each stage.

Methods: The BC Hepatitis Testers Cohort (BC-HTC) includes 1.5million individuals tested for HCV, HIV, reported cases of hepatitis B, and active tuberculosis in BC from 1990 to 2013 linked to medical visits, hospitalizations, cancers, prescription drugs and mortality data. We defined six HCV cascade of care stages: 1) estimated population prevalence; 2) HCV diagnosed; 3) HCV RNA tested; 4) genotyped; 5) initiated treatment; and 6) achieved sustained virologic response (SVR).

Results: We estimated that 73,203 people were HCV antibody positive in BC in 2012 (undiagnosed: 18,301, 25%; diagnosed: 54,902, 75%). Of these, 56%(40,656) had HCV RNA testing; 34%(26,300) were genotyped; 12%( 8532 ) had received interferon-based therapy and 7%(5197) had SVR. Males, older birth cohorts, and HBV coinfected were less likely to undergo HCV RNA testing. Among those with chronic HCV infection, 32% had received liver-related care. Retention in liver care was more likely in those with HIV, cirrhosis, and drug/alcohol use and less likely in males and HBV coinfected.

Conclusions: Although there are gaps in HCV RNA testing and genotyping after HCV diagnosis, the major gap in the cascade of care was low treatment initiation. People with comorbidities progressed through the cascade of testing and care but few received treatment.
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http://dx.doi.org/10.1016/j.ebiom.2016.08.035DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5078584PMC
October 2016

Tackling The Co-Epidemic Of Diabetes And Tuberculosis: From Evidence To Policy And Practice.

J Ayub Med Coll Abbottabad 2016 Apr-Jun;28(2):376-381

Department of Public Health, Al-Shifa Trust Eye Hospital, Islamabad, Pakistan.

With the global increase in the diabetic population there is a resurgence of interest in the dual epidemic of diabetes mellitus (DM) and tuberculosis (TB), which has a bidirectional detrimental relationship with negative consequences for co-infected patients. Pakistan is feared to be hit the hardest, occupying fifth position amidst the 22 high burden TB countries, and ranking seventh in the global diabetic burden. The diabetes tuberculosis treatment outcome (DITTO) study was undertaken to determine the impact of diabetes on tuberculosis treatment outcome in Pakistan. The generation of such scientific evidence is useless if it is not utilized for policy making and practice, especially in a developing country like ours with a dearth of resources. In this paper, we have developed a framework for the transfer of scientific evidence regarding the impact of diabetes on TB treatment outcomes into policy and practice. The framework is divided into three components namely; generation of scientific evidence harnessing international and national efforts, informing health policy and practice and addressing other concerns such as social protection, health education and future research.
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December 2017

Risk factors for bloodborne viral hepatitis in healthcare workers of Pakistan: a population based case-control study.

BMJ Open 2014 Jul 24;4(7):e004767. Epub 2014 Jul 24.

Department of General Surgery, Dow University of Health Sciences, Karachi, Pakistan.

Objectives: A high prevalence of viral hepatitis B and C was found among healthcare workers during a province-wide screening in Sindh Province, Pakistan. A follow-up study was undertaken to identify risk factors for this high prevalence in healthcare workers.

Design: Population based case-control design.

Setting: Public sector healthcare facilities in a rural district of Pakistan.

Participants: Healthcare workers who were screened for hepatitis B surface antigen (HBsAg) and hepatitis C virus (HCV) antibodies. 178 healthcare workers employed at the public sector clinics and hospitals of the district were approached, of which 14 refused to participate. Cases had detectable serum antibodies against HCV and the presence of HBsAg. Healthcare workers non-reactive to HCV antibodies and with no HBsAg were controls. These were matched in a ratio of 1:1.

Outcome Measure: Detectable serum HBsAg and HCV antibody titer were taken as outcome. OR for various exposures was calculated; those with p<0.25 were entered in a multivariate logistic regression model to find out significant predictors.

Results: Needle stick injury (OR=6; CI95 1.4 to 23), recapping the needle (OR=5.7; CI95 1.1 to 28), wound care at accident and emergency of a hospital (OR=5.5; CI95 1 to 28), female gender (OR=3.4; CI95 1 to 12) and more than 10 years of formal education (OR=0.25; CI95 0.07 to 0.8) were associated with hepatitis C. Hepatitis B was found to be associated with trying to bend or break a needle after use (OR=4.9; CI95 1 to 24).

Conclusions: Healthcare workers in Pakistan are at additional risk of exposure to bloodborne pathogens. Bi-dimensional risk factors present at individual and broader health systems levels are responsible. Occupational safety, health trainings and redesigning of the curriculum for allied health professionals are required.
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http://dx.doi.org/10.1136/bmjopen-2013-004767DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4120316PMC
July 2014

Correlates of cigarette smoking among male college students in Karachi, Pakistan.

BMC Public Health 2007 Nov 1;7:312. Epub 2007 Nov 1.

Division of Epidemiology and Biostatistics, Department of Community Health Sciences, Aga Khan University, Stadium Road, PO Box 3500, Karachi, Pakistan.

Background: About 1.3 billion people are regular smokers world wide and every day between 8,200 and 9,900 young people start to smoke, risking rapid addiction to nicotine. Transition from high school to college is a critical period to adopt healthy habits and life style. Therefore, it is important to understand the factors that might influence their smoking habit. Our study aims to assess the influence of factors that encourage college students to smoke cigarettes.

Methods: The data used in this survey were obtained from a representative sample of registered colleges of Karachi. A random sample of 576 male college students of ages ranging from 15-30 years was interviewed using a questionnaire administered by survey officers, by applying multi stage cluster sampling during the academic year 2004-2005.

Results: In this study, we found 26.7% of students had ever tried smoking, whereas 24%(95% CI: 21.0%-28.0%) of college students reported current smoking (that is whether one had smoked a cigarette in past 30 days). Among different age groups, prevalence of current smoking was 19.2% in 15-17 years, 26.5% in 18-20 years and 65% in 21 years and above. After adjusting for age of respondent, students in public schools were more likely to smoke as compared to students in private schools (adjusted OR = 2.3; 95% CI: 1.3-4.2). Students whose friends are smokers were 5 times more likely to smoke compared to those whose friends are non-smokers (adjusted OR = 4.8; 95%CI: 3.1 - 7.4). Those students having fathers with no formal schooling were more likely to smoke (adjusted OR = 2.2; 95% CI: 1.1-4.2) as compared to those whose fathers had some degree of education. Students having non-working mothers were more likely to smoke as compared to students with working mothers (adjusted OR = 2.8; 95% CI: 0.9-9.1). Students belonging to Bin Qasim (adjusted OR = 2.1; 95% C.I: 1.1-4.1) and Gadap town (adjusted OR = 2.1; 95%C.I) were more likely to smoke as compared to students residing in other towns.

Conclusion: This study shows that smoking is strongly associated with age, which may suggest social tolerance to smoking in this setting and that social and educational variables appear to play a significant role in smoking among college students. Our study suggests that such factors should be taken into account when designing effective tobacco control programs among college students. This is an effort which has been done to reduce tobacco consumption among college students and introduce awareness programs to amend their health risk behavior.
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http://dx.doi.org/10.1186/1471-2458-7-312DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2222162PMC
November 2007