Amy Karon

Patients with severe psoriasis were nearly 70% more likely to develop abdominal aortic aneurysms compared with the general population, according to a Danish population-based cohort study.

The findings augment existing evidence linking psoriasis and cardiovascular diseases, wrote Dr. Usman Khalid of Copenhagen University Herlev and Gentofte Hospital, Denmark. The report was published online April 14 in Arteriosclerosis, Thrombosis, and Vascular Biology.

While the mechanisms for the link are unclear, “emerging evidence suggests that AAA is a focal representation of a systemic disease with a distinct inflammatory component, rather than a mere consequence of atherosclerosis,” wrote Dr. Khalid and his associates.

Several case series have linked AAA with other autoimmune disorders, including systemic lupus erythematosus and rheumatoid arthritis, they noted. Their study comprised nearly 5.5 million adults in Denmark between 1997 and 2011. The researchers identified 59,423 patients with mild psoriasis and 11,566 patients with severe psoriasis (Arterioscler Thromb Vasc Biol. 2016 April 14. doi: 10.1161/ATVBAHA.116.307449).

The incidence of AAA in the reference population was 3.72 cases per 10,000 person-years, with an average follow-up period of 14.4 years. In contrast, the incidence of AAA in patients with mild psoriasis was 7.30 cases per 10,000 person-years, and the rate in patients with severe psoriasis was 9.87 cases of per 10,000 person-years, with average follow-up periods of 5.7 years. Both mild and severe psoriasis were significantly associated with AAA after the researchers accounted for age, sex, comorbidities, medications, socioeconomic status, and smoking, with adjusted incidence rate ratios of 1.20 (95% confidence interval, 1.03-1.39) and 1.67 (95% CI, 1.21-2.32), respectively.

The historical view that AAA is caused mainly by atherosclerosis has largely been upended, the researchers noted. Instead, AAA appears to be a multifactorial process involving inflammation, matrix degradation, thrombosis, and aortic wall stress. Furthermore, inflammation in both AAA and psoriasis is centrally mediated by T-helper-17 cells and interleukin-17. Together, the data suggest that shared inflammatory mechanisms link psoriasis and AAA, especially because the association correlates with psoriatic disease activity, they said. “This finding clearly requires independent replication, and the clinical consequences are unclear at present.”

The LEO Foundation and the Novo Nordisk Foundation funded the study. Dr. Khalid had no disclosures. Four coinvestigators reported financial ties with Abbott, Pfizer, AstraZeneca, Bayer, and several other pharmaceutical companies.

Patients with severe psoriasis were nearly 70% more likely to develop abdominal aortic aneurysms compared with the general population, according to a Danish population-based cohort study.

The findings augment existing evidence linking psoriasis and cardiovascular diseases, wrote Dr. Usman Khalid of Copenhagen University Herlev and Gentofte Hospital, Denmark. The report was published online April 14 in Arteriosclerosis, Thrombosis, and Vascular Biology.

While the mechanisms for the link are unclear, “emerging evidence suggests that AAA is a focal representation of a systemic disease with a distinct inflammatory component, rather than a mere consequence of atherosclerosis,” wrote Dr. Khalid and his associates.

Several case series have linked AAA with other autoimmune disorders, including systemic lupus erythematosus and rheumatoid arthritis, they noted. Their study comprised nearly 5.5 million adults in Denmark between 1997 and 2011. The researchers identified 59,423 patients with mild psoriasis and 11,566 patients with severe psoriasis (Arterioscler Thromb Vasc Biol. 2016 April 14. doi: 10.1161/ATVBAHA.116.307449).

The incidence of AAA in the reference population was 3.72 cases per 10,000 person-years, with an average follow-up period of 14.4 years. In contrast, the incidence of AAA in patients with mild psoriasis was 7.30 cases per 10,000 person-years, and the rate in patients with severe psoriasis was 9.87 cases of per 10,000 person-years, with average follow-up periods of 5.7 years. Both mild and severe psoriasis were significantly associated with AAA after the researchers accounted for age, sex, comorbidities, medications, socioeconomic status, and smoking, with adjusted incidence rate ratios of 1.20 (95% confidence interval, 1.03-1.39) and 1.67 (95% CI, 1.21-2.32), respectively.

The historical view that AAA is caused mainly by atherosclerosis has largely been upended, the researchers noted. Instead, AAA appears to be a multifactorial process involving inflammation, matrix degradation, thrombosis, and aortic wall stress. Furthermore, inflammation in both AAA and psoriasis is centrally mediated by T-helper-17 cells and interleukin-17. Together, the data suggest that shared inflammatory mechanisms link psoriasis and AAA, especially because the association correlates with psoriatic disease activity, they said. “This finding clearly requires independent replication, and the clinical consequences are unclear at present.”

The LEO Foundation and the Novo Nordisk Foundation funded the study. Dr. Khalid had no disclosures. Four coinvestigators reported financial ties with Abbott, Pfizer, AstraZeneca, Bayer, and several other pharmaceutical companies.

Patients with severe psoriasis were nearly 70% more likely to develop abdominal aortic aneurysms compared with the general population, according to a Danish population-based cohort study.

The findings augment existing evidence linking psoriasis and cardiovascular diseases, wrote Dr. Usman Khalid of Copenhagen University Herlev and Gentofte Hospital, Denmark. The report was published online April 14 in Arteriosclerosis, Thrombosis, and Vascular Biology.

While the mechanisms for the link are unclear, “emerging evidence suggests that AAA is a focal representation of a systemic disease with a distinct inflammatory component, rather than a mere consequence of atherosclerosis,” wrote Dr. Khalid and his associates.

Several case series have linked AAA with other autoimmune disorders, including systemic lupus erythematosus and rheumatoid arthritis, they noted. Their study comprised nearly 5.5 million adults in Denmark between 1997 and 2011. The researchers identified 59,423 patients with mild psoriasis and 11,566 patients with severe psoriasis (Arterioscler Thromb Vasc Biol. 2016 April 14. doi: 10.1161/ATVBAHA.116.307449).

The incidence of AAA in the reference population was 3.72 cases per 10,000 person-years, with an average follow-up period of 14.4 years. In contrast, the incidence of AAA in patients with mild psoriasis was 7.30 cases per 10,000 person-years, and the rate in patients with severe psoriasis was 9.87 cases of per 10,000 person-years, with average follow-up periods of 5.7 years. Both mild and severe psoriasis were significantly associated with AAA after the researchers accounted for age, sex, comorbidities, medications, socioeconomic status, and smoking, with adjusted incidence rate ratios of 1.20 (95% confidence interval, 1.03-1.39) and 1.67 (95% CI, 1.21-2.32), respectively.

The historical view that AAA is caused mainly by atherosclerosis has largely been upended, the researchers noted. Instead, AAA appears to be a multifactorial process involving inflammation, matrix degradation, thrombosis, and aortic wall stress. Furthermore, inflammation in both AAA and psoriasis is centrally mediated by T-helper-17 cells and interleukin-17. Together, the data suggest that shared inflammatory mechanisms link psoriasis and AAA, especially because the association correlates with psoriatic disease activity, they said. “This finding clearly requires independent replication, and the clinical consequences are unclear at present.”

The LEO Foundation and the Novo Nordisk Foundation funded the study. Dr. Khalid had no disclosures. Four coinvestigators reported financial ties with Abbott, Pfizer, AstraZeneca, Bayer, and several other pharmaceutical companies.

Patients infected with HIV-1 subtype C failed antiretroviral therapy significantly earlier than did HIV-1B–infected patients, especially when they received ritonavir-boosted protease inhibitors instead of nonnucleoside reverse transcriptase inhibitors, according to a Swedish national cohort study.

“As low- and middle-income countries are poised to scale up second-line antiretroviral therapy containing ritonavir-boosted PIs [protease inhibitors], a concern is that PIs will be less efficient in patients with HIV-1C,” said Dr. Ujjwal Neogi of the Karolinska Institute in Stockholm and his associates. “Studies of new drugs such as integrase inhibitors should be done in patients with HIV-1C and other non-B subtypes, which are responsible for the greatest global HIV burden,” they wrote online in the Lancet HIV.

(Photo: Cynthia Goldsmith, CDC)

HIV-infected patients in low-income and middle-income countries often receive second-line boosted PI-based regimens, but few studies have rigorously looked at treatment response for the HIV-1C subtype, which causes most infections in countries such as Ethiopia, India, and South Africa, the investigators noted. They studied more than 99% of Sweden’s HIV-positive population to identify predictors of virologic failure. The dataset included 1,077 HIV-1B–infected patients and 596 HIV-1C–infected patients; 90% of the latter were immigrants (Lancet HIV. 2016 Mar 14. doi: 10.1016/S2352-3018[16]00023-0).

Predictors of primary virologic failure included higher baseline viral load (odds ratio, 1.8; 95% confidence interval, 1.5-2.2); subtype C infection (OR, 1.75; 1.1-2.9), and boosted PI-based regimens (OR, 1.55; 95% CI, 1.5-2.1). After adjustment for transmission route and duration of antiretroviral therapy, time to secondary virologic failure on boosted PI-based regimens was significantly earlier for HIV-1C–infected patients, compared with HIV-1B patients (hazard ratio, 1.8; 95% CI, 1.3-2.9). However, HIV-1 subtype did not significantly predict time to virologic failure for nonnucleoside reverse transcriptase inhibitor–based regimens.

“The poorer treatment outcome occurred in the patients with HIV-1C despite developed clinical care, modern laboratory monitoring, and focused adherence support at highly HIV-specialized infectious disease clinics in a high-income country,” the researchers wrote. Self-reported adherence to therapy did not differ by treatment regimen or HIV-1 subtype, although adherence data were available for only about a third of HIV-1C–infected patients, they added.

Homology-based molecular modeling also seemed to show a lower affinity between the PIs darunavir and lopinavir and the HIV-1C protease, compared with the HIV-1B protease, said the researchers. “Naturally occurring polymorphisms in HIV-1C protease might affect the binding of at least some protease inhibitors, potentially contributing to the differences we observed,” they concluded.

The study was funded by the Karolinska Institutet Research Foundation, Swedish Research Council, Stockholm County Council, Swedish Physicians against AIDS, National Institutes of Health, and University of Missouri. The investigators had no relevant financial disclosures.

Patients infected with HIV-1 subtype C failed antiretroviral therapy significantly earlier than did HIV-1B–infected patients, especially when they received ritonavir-boosted protease inhibitors instead of nonnucleoside reverse transcriptase inhibitors, according to a Swedish national cohort study.

“As low- and middle-income countries are poised to scale up second-line antiretroviral therapy containing ritonavir-boosted PIs [protease inhibitors], a concern is that PIs will be less efficient in patients with HIV-1C,” said Dr. Ujjwal Neogi of the Karolinska Institute in Stockholm and his associates. “Studies of new drugs such as integrase inhibitors should be done in patients with HIV-1C and other non-B subtypes, which are responsible for the greatest global HIV burden,” they wrote online in the Lancet HIV.

(Photo: Cynthia Goldsmith, CDC)

HIV-infected patients in low-income and middle-income countries often receive second-line boosted PI-based regimens, but few studies have rigorously looked at treatment response for the HIV-1C subtype, which causes most infections in countries such as Ethiopia, India, and South Africa, the investigators noted. They studied more than 99% of Sweden’s HIV-positive population to identify predictors of virologic failure. The dataset included 1,077 HIV-1B–infected patients and 596 HIV-1C–infected patients; 90% of the latter were immigrants (Lancet HIV. 2016 Mar 14. doi: 10.1016/S2352-3018[16]00023-0).

Predictors of primary virologic failure included higher baseline viral load (odds ratio, 1.8; 95% confidence interval, 1.5-2.2); subtype C infection (OR, 1.75; 1.1-2.9), and boosted PI-based regimens (OR, 1.55; 95% CI, 1.5-2.1). After adjustment for transmission route and duration of antiretroviral therapy, time to secondary virologic failure on boosted PI-based regimens was significantly earlier for HIV-1C–infected patients, compared with HIV-1B patients (hazard ratio, 1.8; 95% CI, 1.3-2.9). However, HIV-1 subtype did not significantly predict time to virologic failure for nonnucleoside reverse transcriptase inhibitor–based regimens.

“The poorer treatment outcome occurred in the patients with HIV-1C despite developed clinical care, modern laboratory monitoring, and focused adherence support at highly HIV-specialized infectious disease clinics in a high-income country,” the researchers wrote. Self-reported adherence to therapy did not differ by treatment regimen or HIV-1 subtype, although adherence data were available for only about a third of HIV-1C–infected patients, they added.

Homology-based molecular modeling also seemed to show a lower affinity between the PIs darunavir and lopinavir and the HIV-1C protease, compared with the HIV-1B protease, said the researchers. “Naturally occurring polymorphisms in HIV-1C protease might affect the binding of at least some protease inhibitors, potentially contributing to the differences we observed,” they concluded.

The study was funded by the Karolinska Institutet Research Foundation, Swedish Research Council, Stockholm County Council, Swedish Physicians against AIDS, National Institutes of Health, and University of Missouri. The investigators had no relevant financial disclosures.

Patients infected with HIV-1 subtype C failed antiretroviral therapy significantly earlier than did HIV-1B–infected patients, especially when they received ritonavir-boosted protease inhibitors instead of nonnucleoside reverse transcriptase inhibitors, according to a Swedish national cohort study.

“As low- and middle-income countries are poised to scale up second-line antiretroviral therapy containing ritonavir-boosted PIs [protease inhibitors], a concern is that PIs will be less efficient in patients with HIV-1C,” said Dr. Ujjwal Neogi of the Karolinska Institute in Stockholm and his associates. “Studies of new drugs such as integrase inhibitors should be done in patients with HIV-1C and other non-B subtypes, which are responsible for the greatest global HIV burden,” they wrote online in the Lancet HIV.

(Photo: Cynthia Goldsmith, CDC)

HIV-infected patients in low-income and middle-income countries often receive second-line boosted PI-based regimens, but few studies have rigorously looked at treatment response for the HIV-1C subtype, which causes most infections in countries such as Ethiopia, India, and South Africa, the investigators noted. They studied more than 99% of Sweden’s HIV-positive population to identify predictors of virologic failure. The dataset included 1,077 HIV-1B–infected patients and 596 HIV-1C–infected patients; 90% of the latter were immigrants (Lancet HIV. 2016 Mar 14. doi: 10.1016/S2352-3018[16]00023-0).

Predictors of primary virologic failure included higher baseline viral load (odds ratio, 1.8; 95% confidence interval, 1.5-2.2); subtype C infection (OR, 1.75; 1.1-2.9), and boosted PI-based regimens (OR, 1.55; 95% CI, 1.5-2.1). After adjustment for transmission route and duration of antiretroviral therapy, time to secondary virologic failure on boosted PI-based regimens was significantly earlier for HIV-1C–infected patients, compared with HIV-1B patients (hazard ratio, 1.8; 95% CI, 1.3-2.9). However, HIV-1 subtype did not significantly predict time to virologic failure for nonnucleoside reverse transcriptase inhibitor–based regimens.

“The poorer treatment outcome occurred in the patients with HIV-1C despite developed clinical care, modern laboratory monitoring, and focused adherence support at highly HIV-specialized infectious disease clinics in a high-income country,” the researchers wrote. Self-reported adherence to therapy did not differ by treatment regimen or HIV-1 subtype, although adherence data were available for only about a third of HIV-1C–infected patients, they added.

Homology-based molecular modeling also seemed to show a lower affinity between the PIs darunavir and lopinavir and the HIV-1C protease, compared with the HIV-1B protease, said the researchers. “Naturally occurring polymorphisms in HIV-1C protease might affect the binding of at least some protease inhibitors, potentially contributing to the differences we observed,” they concluded.

The study was funded by the Karolinska Institutet Research Foundation, Swedish Research Council, Stockholm County Council, Swedish Physicians against AIDS, National Institutes of Health, and University of Missouri. The investigators had no relevant financial disclosures.

Patients infected with HIV-1 subtype C failed antiretroviral therapy significantly earlier than did HIV-1B–infected patients, especially when they received ritonavir-boosted protease inhibitors instead of nonnucleoside reverse transcriptase inhibitors, according to a Swedish national cohort study.

“As low- and middle-income countries are poised to scale up second-line antiretroviral therapy containing ritonavir-boosted PIs [protease inhibitors], a concern is that PIs will be less efficient in patients with HIV-1C,” said Dr. Ujjwal Neogi of the Karolinska Institute in Stockholm and his associates. “Studies of new drugs such as integrase inhibitors should be done in patients with HIV-1C and other non-B subtypes, which are responsible for the greatest global HIV burden,” they wrote online in the Lancet HIV.

(Photo: Cynthia Goldsmith, CDC)

HIV-infected patients in low-income and middle-income countries often receive second-line boosted PI-based regimens, but few studies have rigorously looked at treatment response for the HIV-1C subtype, which causes most infections in countries such as Ethiopia, India, and South Africa, the investigators noted. They studied more than 99% of Sweden’s HIV-positive population to identify predictors of virologic failure. The dataset included 1,077 HIV-1B–infected patients and 596 HIV-1C–infected patients; 90% of the latter were immigrants (Lancet HIV. 2016 Mar 14. doi: 10.1016/S2352-3018[16]00023-0).

Predictors of primary virologic failure included higher baseline viral load (odds ratio, 1.8; 95% confidence interval, 1.5-2.2); subtype C infection (OR, 1.75; 1.1-2.9), and boosted PI-based regimens (OR, 1.55; 95% CI, 1.5-2.1). After adjustment for transmission route and duration of antiretroviral therapy, time to secondary virologic failure on boosted PI-based regimens was significantly earlier for HIV-1C–infected patients, compared with HIV-1B patients (hazard ratio, 1.8; 95% CI, 1.3-2.9). However, HIV-1 subtype did not significantly predict time to virologic failure for nonnucleoside reverse transcriptase inhibitor–based regimens.

“The poorer treatment outcome occurred in the patients with HIV-1C despite developed clinical care, modern laboratory monitoring, and focused adherence support at highly HIV-specialized infectious disease clinics in a high-income country,” the researchers wrote. Self-reported adherence to therapy did not differ by treatment regimen or HIV-1 subtype, although adherence data were available for only about a third of HIV-1C–infected patients, they added.

Homology-based molecular modeling also seemed to show a lower affinity between the PIs darunavir and lopinavir and the HIV-1C protease, compared with the HIV-1B protease, said the researchers. “Naturally occurring polymorphisms in HIV-1C protease might affect the binding of at least some protease inhibitors, potentially contributing to the differences we observed,” they concluded.

The study was funded by the Karolinska Institutet Research Foundation, Swedish Research Council, Stockholm County Council, Swedish Physicians against AIDS, National Institutes of Health, and University of Missouri. The investigators had no relevant financial disclosures.

Patients infected with HIV-1 subtype C failed antiretroviral therapy significantly earlier than did HIV-1B–infected patients, especially when they received ritonavir-boosted protease inhibitors instead of nonnucleoside reverse transcriptase inhibitors, according to a Swedish national cohort study.

“As low- and middle-income countries are poised to scale up second-line antiretroviral therapy containing ritonavir-boosted PIs [protease inhibitors], a concern is that PIs will be less efficient in patients with HIV-1C,” said Dr. Ujjwal Neogi of the Karolinska Institute in Stockholm and his associates. “Studies of new drugs such as integrase inhibitors should be done in patients with HIV-1C and other non-B subtypes, which are responsible for the greatest global HIV burden,” they wrote online in the Lancet HIV.

(Photo: Cynthia Goldsmith, CDC)

HIV-infected patients in low-income and middle-income countries often receive second-line boosted PI-based regimens, but few studies have rigorously looked at treatment response for the HIV-1C subtype, which causes most infections in countries such as Ethiopia, India, and South Africa, the investigators noted. They studied more than 99% of Sweden’s HIV-positive population to identify predictors of virologic failure. The dataset included 1,077 HIV-1B–infected patients and 596 HIV-1C–infected patients; 90% of the latter were immigrants (Lancet HIV. 2016 Mar 14. doi: 10.1016/S2352-3018[16]00023-0).

Predictors of primary virologic failure included higher baseline viral load (odds ratio, 1.8; 95% confidence interval, 1.5-2.2); subtype C infection (OR, 1.75; 1.1-2.9), and boosted PI-based regimens (OR, 1.55; 95% CI, 1.5-2.1). After adjustment for transmission route and duration of antiretroviral therapy, time to secondary virologic failure on boosted PI-based regimens was significantly earlier for HIV-1C–infected patients, compared with HIV-1B patients (hazard ratio, 1.8; 95% CI, 1.3-2.9). However, HIV-1 subtype did not significantly predict time to virologic failure for nonnucleoside reverse transcriptase inhibitor–based regimens.

“The poorer treatment outcome occurred in the patients with HIV-1C despite developed clinical care, modern laboratory monitoring, and focused adherence support at highly HIV-specialized infectious disease clinics in a high-income country,” the researchers wrote. Self-reported adherence to therapy did not differ by treatment regimen or HIV-1 subtype, although adherence data were available for only about a third of HIV-1C–infected patients, they added.

Homology-based molecular modeling also seemed to show a lower affinity between the PIs darunavir and lopinavir and the HIV-1C protease, compared with the HIV-1B protease, said the researchers. “Naturally occurring polymorphisms in HIV-1C protease might affect the binding of at least some protease inhibitors, potentially contributing to the differences we observed,” they concluded.

The study was funded by the Karolinska Institutet Research Foundation, Swedish Research Council, Stockholm County Council, Swedish Physicians against AIDS, National Institutes of Health, and University of Missouri. The investigators had no relevant financial disclosures.

Patients infected with HIV-1 subtype C failed antiretroviral therapy significantly earlier than did HIV-1B–infected patients, especially when they received ritonavir-boosted protease inhibitors instead of nonnucleoside reverse transcriptase inhibitors, according to a Swedish national cohort study.

“As low- and middle-income countries are poised to scale up second-line antiretroviral therapy containing ritonavir-boosted PIs [protease inhibitors], a concern is that PIs will be less efficient in patients with HIV-1C,” said Dr. Ujjwal Neogi of the Karolinska Institute in Stockholm and his associates. “Studies of new drugs such as integrase inhibitors should be done in patients with HIV-1C and other non-B subtypes, which are responsible for the greatest global HIV burden,” they wrote online in the Lancet HIV.

(Photo: Cynthia Goldsmith, CDC)

HIV-infected patients in low-income and middle-income countries often receive second-line boosted PI-based regimens, but few studies have rigorously looked at treatment response for the HIV-1C subtype, which causes most infections in countries such as Ethiopia, India, and South Africa, the investigators noted. They studied more than 99% of Sweden’s HIV-positive population to identify predictors of virologic failure. The dataset included 1,077 HIV-1B–infected patients and 596 HIV-1C–infected patients; 90% of the latter were immigrants (Lancet HIV. 2016 Mar 14. doi: 10.1016/S2352-3018[16]00023-0).

Predictors of primary virologic failure included higher baseline viral load (odds ratio, 1.8; 95% confidence interval, 1.5-2.2); subtype C infection (OR, 1.75; 1.1-2.9), and boosted PI-based regimens (OR, 1.55; 95% CI, 1.5-2.1). After adjustment for transmission route and duration of antiretroviral therapy, time to secondary virologic failure on boosted PI-based regimens was significantly earlier for HIV-1C–infected patients, compared with HIV-1B patients (hazard ratio, 1.8; 95% CI, 1.3-2.9). However, HIV-1 subtype did not significantly predict time to virologic failure for nonnucleoside reverse transcriptase inhibitor–based regimens.

“The poorer treatment outcome occurred in the patients with HIV-1C despite developed clinical care, modern laboratory monitoring, and focused adherence support at highly HIV-specialized infectious disease clinics in a high-income country,” the researchers wrote. Self-reported adherence to therapy did not differ by treatment regimen or HIV-1 subtype, although adherence data were available for only about a third of HIV-1C–infected patients, they added.

Homology-based molecular modeling also seemed to show a lower affinity between the PIs darunavir and lopinavir and the HIV-1C protease, compared with the HIV-1B protease, said the researchers. “Naturally occurring polymorphisms in HIV-1C protease might affect the binding of at least some protease inhibitors, potentially contributing to the differences we observed,” they concluded.

The study was funded by the Karolinska Institutet Research Foundation, Swedish Research Council, Stockholm County Council, Swedish Physicians against AIDS, National Institutes of Health, and University of Missouri. The investigators had no relevant financial disclosures.

Zika virus infection in adults often causes pruritic maculopapular rash, but rarely leads to clinically significant fever, according to two cohort studies in Rio de Janeiro.

The findings raise questions about case definitions of Zika virus disease (ZVD).

“In our opinion, pruritus, the second most common clinical sign presented by the confirmed cases, should be added to the Pan American Health Organization case definition [for Zika virus disease], while fever could be given less emphasis,” Dr. Patricia Brasil of the Oswaldo Cruz Foundation in Rio de Janeiro and her associates wrote online April 12 in PLoS Neglected Tropical Diseases.

Dr. Stephen K. Tyring, Dr. Zeena Nawas, The University of Texas Health Science Center at Houston

Watching for a combination of itching and rash also could help distinguish Zika virus disease from infections of Chikungunya and Dengue, co-circulating arboviruses in Brazil that tend to cause nonpruritic rash, the investigators noted. Distinguishing these infections is crucial because Dengue, in particular, can be devastating without appropriate treatment (doi: 10.1371/journal.pntd.0004636).

Brazil confirmed Zika virus disease in the northeastern state of Bahia in May 2015. Cases in Rio de Janeiro soon followed, triggering worries because of its dense population and status as host of the 2016 Olympic and Paralympic Games. To better characterize Zika virus disease in Rio de Janeiro, Dr. Brasil and her associates studied 364 cases of acute rash, with or without fever, among adults with clinical onset during the first half of 2015. Quantitative reverse transcription–polymerase chain reaction detected Zika viral RNA in blood samples from 119 (45%) of 262 patients tested.

The first 4 days of confirmed ZVD were marked by rash (97%), itching (79%), prostration (73%), headache (66%), arthralgias (63%), and myalgia (61%). Just 36% of patients were febrile, and fevers usually were short-lived and low-grade, in contrast to other arboviral infections. Partial sequencing of the Zika virus gene from 10 randomly selected positive samples showed that it resembled Asian strains of Zika virus, supporting the hypothesis that Pacific Islanders brought Zika to Rio de Janeiro during a canoe championship in 2014, the researchers added.

The researchers also determined that Zika virus was circulating in Rio de Janeiro as early as January 2015 – “at least five months before its detection was announced by the health authorities, which must be taken into consideration for future design and implementation of effective syndromic surveillance systems,” they wrote. Surprisingly, an assay for Dengue was negative in all 250 patients tested, which might indicate “explosive transmission dynamics of Zika virus disease,” the investigators added.

A retrospective cohort study of confirmed Zika virus cases in Rio de Janeiro also reported a much higher prevalence of rash compared with fever (Emerg Infect Dis. 2016 Jul. doi: 10.3201/eid2207.160375).

This was a retrospective convenience sample of 57 patients, including 98% with rash, 56% with pruritus, and 67% with measured or self-reported fever. Most fevers were low-grade, and the median recorded temperature was 30.0 degrees Celsius (within normal limits). Other common presentations included headache (67%), arthralgias (58%), myalgias (49%), and joint swelling (23%), according to Dr. Jose Cerbino-Neto of the Oswaldo Cruz Foundation in Rio de Janeiro and his associates. Their findings support emphasizing rash, fever, or both as “primary characteristics” of ZVD, they added. Currently, the interim case definition from the World Health Organization defines a suspected Zika virus disease case as rash, fever, or both, plus at least one of three other symptoms – arthralgia, arthritis, or conjunctivitis.

The study by Dr. Brasil and her associates was funded by Conselho Nacional de Desenvolvimento Cientifico e Tecnologico, the Fundacao de Amparo a Pesquisa no Estado do Rio de Janeiro, and the European Commission. Dr. Brasil and her coinvestigators had no disclosures. Dr. Cerbino-Neto reported no funding sources or conflicts of interest.

Zika virus infection in adults often causes pruritic maculopapular rash, but rarely leads to clinically significant fever, according to two cohort studies in Rio de Janeiro.

The findings raise questions about case definitions of Zika virus disease (ZVD).

“In our opinion, pruritus, the second most common clinical sign presented by the confirmed cases, should be added to the Pan American Health Organization case definition [for Zika virus disease], while fever could be given less emphasis,” Dr. Patricia Brasil of the Oswaldo Cruz Foundation in Rio de Janeiro and her associates wrote online April 12 in PLoS Neglected Tropical Diseases.

Dr. Stephen K. Tyring, Dr. Zeena Nawas, The University of Texas Health Science Center at Houston

Watching for a combination of itching and rash also could help distinguish Zika virus disease from infections of Chikungunya and Dengue, co-circulating arboviruses in Brazil that tend to cause nonpruritic rash, the investigators noted. Distinguishing these infections is crucial because Dengue, in particular, can be devastating without appropriate treatment (doi: 10.1371/journal.pntd.0004636).

Brazil confirmed Zika virus disease in the northeastern state of Bahia in May 2015. Cases in Rio de Janeiro soon followed, triggering worries because of its dense population and status as host of the 2016 Olympic and Paralympic Games. To better characterize Zika virus disease in Rio de Janeiro, Dr. Brasil and her associates studied 364 cases of acute rash, with or without fever, among adults with clinical onset during the first half of 2015. Quantitative reverse transcription–polymerase chain reaction detected Zika viral RNA in blood samples from 119 (45%) of 262 patients tested.

The first 4 days of confirmed ZVD were marked by rash (97%), itching (79%), prostration (73%), headache (66%), arthralgias (63%), and myalgia (61%). Just 36% of patients were febrile, and fevers usually were short-lived and low-grade, in contrast to other arboviral infections. Partial sequencing of the Zika virus gene from 10 randomly selected positive samples showed that it resembled Asian strains of Zika virus, supporting the hypothesis that Pacific Islanders brought Zika to Rio de Janeiro during a canoe championship in 2014, the researchers added.

The researchers also determined that Zika virus was circulating in Rio de Janeiro as early as January 2015 – “at least five months before its detection was announced by the health authorities, which must be taken into consideration for future design and implementation of effective syndromic surveillance systems,” they wrote. Surprisingly, an assay for Dengue was negative in all 250 patients tested, which might indicate “explosive transmission dynamics of Zika virus disease,” the investigators added.

A retrospective cohort study of confirmed Zika virus cases in Rio de Janeiro also reported a much higher prevalence of rash compared with fever (Emerg Infect Dis. 2016 Jul. doi: 10.3201/eid2207.160375).

This was a retrospective convenience sample of 57 patients, including 98% with rash, 56% with pruritus, and 67% with measured or self-reported fever. Most fevers were low-grade, and the median recorded temperature was 30.0 degrees Celsius (within normal limits). Other common presentations included headache (67%), arthralgias (58%), myalgias (49%), and joint swelling (23%), according to Dr. Jose Cerbino-Neto of the Oswaldo Cruz Foundation in Rio de Janeiro and his associates. Their findings support emphasizing rash, fever, or both as “primary characteristics” of ZVD, they added. Currently, the interim case definition from the World Health Organization defines a suspected Zika virus disease case as rash, fever, or both, plus at least one of three other symptoms – arthralgia, arthritis, or conjunctivitis.

The study by Dr. Brasil and her associates was funded by Conselho Nacional de Desenvolvimento Cientifico e Tecnologico, the Fundacao de Amparo a Pesquisa no Estado do Rio de Janeiro, and the European Commission. Dr. Brasil and her coinvestigators had no disclosures. Dr. Cerbino-Neto reported no funding sources or conflicts of interest.

Zika virus infection in adults often causes pruritic maculopapular rash, but rarely leads to clinically significant fever, according to two cohort studies in Rio de Janeiro.

The findings raise questions about case definitions of Zika virus disease (ZVD).

“In our opinion, pruritus, the second most common clinical sign presented by the confirmed cases, should be added to the Pan American Health Organization case definition [for Zika virus disease], while fever could be given less emphasis,” Dr. Patricia Brasil of the Oswaldo Cruz Foundation in Rio de Janeiro and her associates wrote online April 12 in PLoS Neglected Tropical Diseases.

Dr. Stephen K. Tyring, Dr. Zeena Nawas, The University of Texas Health Science Center at Houston

Watching for a combination of itching and rash also could help distinguish Zika virus disease from infections of Chikungunya and Dengue, co-circulating arboviruses in Brazil that tend to cause nonpruritic rash, the investigators noted. Distinguishing these infections is crucial because Dengue, in particular, can be devastating without appropriate treatment (doi: 10.1371/journal.pntd.0004636).

Brazil confirmed Zika virus disease in the northeastern state of Bahia in May 2015. Cases in Rio de Janeiro soon followed, triggering worries because of its dense population and status as host of the 2016 Olympic and Paralympic Games. To better characterize Zika virus disease in Rio de Janeiro, Dr. Brasil and her associates studied 364 cases of acute rash, with or without fever, among adults with clinical onset during the first half of 2015. Quantitative reverse transcription–polymerase chain reaction detected Zika viral RNA in blood samples from 119 (45%) of 262 patients tested.

The first 4 days of confirmed ZVD were marked by rash (97%), itching (79%), prostration (73%), headache (66%), arthralgias (63%), and myalgia (61%). Just 36% of patients were febrile, and fevers usually were short-lived and low-grade, in contrast to other arboviral infections. Partial sequencing of the Zika virus gene from 10 randomly selected positive samples showed that it resembled Asian strains of Zika virus, supporting the hypothesis that Pacific Islanders brought Zika to Rio de Janeiro during a canoe championship in 2014, the researchers added.

The researchers also determined that Zika virus was circulating in Rio de Janeiro as early as January 2015 – “at least five months before its detection was announced by the health authorities, which must be taken into consideration for future design and implementation of effective syndromic surveillance systems,” they wrote. Surprisingly, an assay for Dengue was negative in all 250 patients tested, which might indicate “explosive transmission dynamics of Zika virus disease,” the investigators added.

A retrospective cohort study of confirmed Zika virus cases in Rio de Janeiro also reported a much higher prevalence of rash compared with fever (Emerg Infect Dis. 2016 Jul. doi: 10.3201/eid2207.160375).

This was a retrospective convenience sample of 57 patients, including 98% with rash, 56% with pruritus, and 67% with measured or self-reported fever. Most fevers were low-grade, and the median recorded temperature was 30.0 degrees Celsius (within normal limits). Other common presentations included headache (67%), arthralgias (58%), myalgias (49%), and joint swelling (23%), according to Dr. Jose Cerbino-Neto of the Oswaldo Cruz Foundation in Rio de Janeiro and his associates. Their findings support emphasizing rash, fever, or both as “primary characteristics” of ZVD, they added. Currently, the interim case definition from the World Health Organization defines a suspected Zika virus disease case as rash, fever, or both, plus at least one of three other symptoms – arthralgia, arthritis, or conjunctivitis.

The study by Dr. Brasil and her associates was funded by Conselho Nacional de Desenvolvimento Cientifico e Tecnologico, the Fundacao de Amparo a Pesquisa no Estado do Rio de Janeiro, and the European Commission. Dr. Brasil and her coinvestigators had no disclosures. Dr. Cerbino-Neto reported no funding sources or conflicts of interest.

The Food and Drug Administration has approved the first leadless pacemaker, the Micra transcatheter pacing system, the FDA stated in a release accompanying its approval.

The Micra pacemaker eliminates the need for wired leads and the risk of associated complications. The single-chamber ventricular pacemaker is 93% smaller than traditional pacemakers, according to a summary document submitted to the FDA by Medtronic, which makes the device. Like other ventricular pacemakers, Micra provides rate-adaptive pacing, with automated pacing capture threshold management to maximize battery life, which the company estimates at about 10 years.

Courtesy Medtronic plc

The pacemaker is inserted directly into the right ventricle through the femoral vein by means of a steerable catheter. Pressing a button on the distal end of the catheter releases four flexible, electrically inactive nitinol tines that hook into the myocardium to secure the device. Engagement by two tines exerts 15 times the amount of force needed to secure the device in place, according to Medtronic.

The device’s approval was based on a pivotal prospective, nonrandomized uncontrolled study of 719 patients at 56 investigational sites in North America, Europe, Asia, Australia, and Africa. The primary efficacy endpoint, low and stable pacing capture thresholds at 6 months (up to 2.0 V at a pulse width of 0.24 milliseconds and an increase of up to 1.5 V from the time of implantation) was achieved for 98% of patients (95% confidence interval, 96%-99.5%), reported Dr. Dwight Reynolds of the University of Oklahoma Health Sciences Center in Oklahoma City and his associates (N Engl J Med. 2016 Feb. 11. doi: 10.1056/NEJMoa1511643).

The researchers also compared safety outcomes among Micra recipients and 2,667 historical controls from six previously published studies. The Micra pacemaker was associated with significantly lower hospitalization and system revision rates, with “no systemic infections, no pneumothoraxes, and no radiographically visible dislodgements or device emboli,” they said. In all, 4% of Micra recipients had complications leading to death or requiring invasive revision, treatment cessation, or hospitalization, which resembled recent reports of transvenous systems and was significantly lower than the rate for historical controls, according to the investigators. However, the rate of cardiac perforation or effusion was 1.6%, slightly higher than the rate of 1.1% for historical controls. Other major complications included cardiac failure (0.9% of study patients), atrioventricular fistula or pseudoaneurysm at the groin puncture site (0.7%), and deep vein thrombosis or pulmonary thromboembolism (0.3%).

Medtronic funded the pivotal study on which approval of the Micra pacemaker was based. Dr. Reynolds had no relevant financial disclosures. Several coinvestigators reported financial relationships with Medtronic and several other cardiac device manufacturers.

The Food and Drug Administration has approved the first leadless pacemaker, the Micra transcatheter pacing system, the FDA stated in a release accompanying its approval.

The Micra pacemaker eliminates the need for wired leads and the risk of associated complications. The single-chamber ventricular pacemaker is 93% smaller than traditional pacemakers, according to a summary document submitted to the FDA by Medtronic, which makes the device. Like other ventricular pacemakers, Micra provides rate-adaptive pacing, with automated pacing capture threshold management to maximize battery life, which the company estimates at about 10 years.

Courtesy Medtronic plc

The pacemaker is inserted directly into the right ventricle through the femoral vein by means of a steerable catheter. Pressing a button on the distal end of the catheter releases four flexible, electrically inactive nitinol tines that hook into the myocardium to secure the device. Engagement by two tines exerts 15 times the amount of force needed to secure the device in place, according to Medtronic.

The device’s approval was based on a pivotal prospective, nonrandomized uncontrolled study of 719 patients at 56 investigational sites in North America, Europe, Asia, Australia, and Africa. The primary efficacy endpoint, low and stable pacing capture thresholds at 6 months (up to 2.0 V at a pulse width of 0.24 milliseconds and an increase of up to 1.5 V from the time of implantation) was achieved for 98% of patients (95% confidence interval, 96%-99.5%), reported Dr. Dwight Reynolds of the University of Oklahoma Health Sciences Center in Oklahoma City and his associates (N Engl J Med. 2016 Feb. 11. doi: 10.1056/NEJMoa1511643).

The researchers also compared safety outcomes among Micra recipients and 2,667 historical controls from six previously published studies. The Micra pacemaker was associated with significantly lower hospitalization and system revision rates, with “no systemic infections, no pneumothoraxes, and no radiographically visible dislodgements or device emboli,” they said. In all, 4% of Micra recipients had complications leading to death or requiring invasive revision, treatment cessation, or hospitalization, which resembled recent reports of transvenous systems and was significantly lower than the rate for historical controls, according to the investigators. However, the rate of cardiac perforation or effusion was 1.6%, slightly higher than the rate of 1.1% for historical controls. Other major complications included cardiac failure (0.9% of study patients), atrioventricular fistula or pseudoaneurysm at the groin puncture site (0.7%), and deep vein thrombosis or pulmonary thromboembolism (0.3%).

Medtronic funded the pivotal study on which approval of the Micra pacemaker was based. Dr. Reynolds had no relevant financial disclosures. Several coinvestigators reported financial relationships with Medtronic and several other cardiac device manufacturers.

The Food and Drug Administration has approved the first leadless pacemaker, the Micra transcatheter pacing system, the FDA stated in a release accompanying its approval.

The Micra pacemaker eliminates the need for wired leads and the risk of associated complications. The single-chamber ventricular pacemaker is 93% smaller than traditional pacemakers, according to a summary document submitted to the FDA by Medtronic, which makes the device. Like other ventricular pacemakers, Micra provides rate-adaptive pacing, with automated pacing capture threshold management to maximize battery life, which the company estimates at about 10 years.

Courtesy Medtronic plc

The pacemaker is inserted directly into the right ventricle through the femoral vein by means of a steerable catheter. Pressing a button on the distal end of the catheter releases four flexible, electrically inactive nitinol tines that hook into the myocardium to secure the device. Engagement by two tines exerts 15 times the amount of force needed to secure the device in place, according to Medtronic.

The device’s approval was based on a pivotal prospective, nonrandomized uncontrolled study of 719 patients at 56 investigational sites in North America, Europe, Asia, Australia, and Africa. The primary efficacy endpoint, low and stable pacing capture thresholds at 6 months (up to 2.0 V at a pulse width of 0.24 milliseconds and an increase of up to 1.5 V from the time of implantation) was achieved for 98% of patients (95% confidence interval, 96%-99.5%), reported Dr. Dwight Reynolds of the University of Oklahoma Health Sciences Center in Oklahoma City and his associates (N Engl J Med. 2016 Feb. 11. doi: 10.1056/NEJMoa1511643).

The researchers also compared safety outcomes among Micra recipients and 2,667 historical controls from six previously published studies. The Micra pacemaker was associated with significantly lower hospitalization and system revision rates, with “no systemic infections, no pneumothoraxes, and no radiographically visible dislodgements or device emboli,” they said. In all, 4% of Micra recipients had complications leading to death or requiring invasive revision, treatment cessation, or hospitalization, which resembled recent reports of transvenous systems and was significantly lower than the rate for historical controls, according to the investigators. However, the rate of cardiac perforation or effusion was 1.6%, slightly higher than the rate of 1.1% for historical controls. Other major complications included cardiac failure (0.9% of study patients), atrioventricular fistula or pseudoaneurysm at the groin puncture site (0.7%), and deep vein thrombosis or pulmonary thromboembolism (0.3%).

Medtronic funded the pivotal study on which approval of the Micra pacemaker was based. Dr. Reynolds had no relevant financial disclosures. Several coinvestigators reported financial relationships with Medtronic and several other cardiac device manufacturers.

The United States can end hepatitis B and C transmission and prevent related morbidity and mortality given enough time, resources, and will to surmount a variety of barriers, according to a new report from the National Academies of Sciences, Engineering, and Medicine.

A more feasible short-term goal is to control viral hepatitis by reducing the incidence and prevalence of hepatitis B (HBV) and C virus (HCV) infections, states the report, which is the first of a two-phase study. The second part, to be published in early 2017, will outline a strategy to achieve the goals.

“Disease elimination” once meant stopping all new infections in a population, but eliminating a public health problem “can be a less absolute goal,” Dr. Brian Strom, chancellor of Rutgers Biomedical and Health Sciences, wrote along with his associates. “The WHO has accepted a non-zero target in its work against viral hepatitis,” they added. “The organization’s provisional target is a 90% reduction in incidence, and a 65% reduction in mortality by 2030.”

Furthermore, those are global targets – countries should base their own strategies on their specific viral hepatitis disease burdens and epidemiologic features, Dr. Strom and his associates emphasized. For example, universal vaccination could eradicate HBV in the United States in two generations, but there is no cure for the 700,000-1.4 million Americans who are already infected. Mother-to-child HBV transmission is rare here, but better screening and surveillance could help prevent the 800-1,000 cases of vertical transmission that still occur annually.

More than a third of newborns in the United States do not receive the HBV vaccination on the day they are born, and 28% remain unvaccinated when they are 3 days old, “but childhood catch-up is possible,” the experts also wrote. Vaccinating adults is more complicated, but targeting high-risk groups such as prison inmates or patients at sexually transmitted disease clinics might work, they added. Vaccination is especially important, because chronically infected HBV patients need lifelong medical follow-up to prevent progression and death from cirrhosis and liver cancer, they emphasized.

The hepatitis C virus presents a different picture – there is no HCV vaccine, while the novel direct-acting antivirals can theoretically cure nearly all chronic infections. But in reality, high drug costs and the massive burden of undiagnosed HCV mean that only a small fraction of patients can be cured, the authors acknowledged. On an individual basis, the benefits of direct-acting antivirals outweigh the costs of treating genotype 1 HCV and associated morbidity, they add. But on a population level, “eliminating HCV infection would require near universal access to treatment, something that appears infeasible given the current pricing and policy environment.”

Several other barriers also impede progress against HBV and HCV. For example, only five states and two large cities receive enough funding for comprehensive viral hepatitis surveillance, Dr. Strom and his associates noted. If local and state public health departments cannot track infections, they cannot characterize their epidemics. In addition, viral hepatitis remains a source of stigma, adding to fear and avoidance of testing and undermining elimination efforts. Stigma, avoidance, and the fact that HBV and HCV are asymptomatic in the early stages all contribute to a large population of chronically infected patients who do not know their status.

Moreover, many state Medicaid programs will not cover foreigners until they have lived in the United States for 5 years, and the Affordable Care Act does not cover care for short-term residents and undocumented immigrants, the report stated. Newly infected HCV patients tend to have fewer resources, lower educational levels, and more often use injection drugs, making them harder to reach and screen through the health system. “Prisons are a promising venue in which to treat HCV, but treating HCV is expensive for the prison system. The cost of the direct-acting antivirals is high, and the staff time required to manage an inmate in treatment often far exceed the available resources,” the report stated.

The study was sponsored by the Centers for Disease Control and Prevention Office of Viral Hepatitis and the U.S. Department of Health and Human Services Office of Minority Health. The authors disclosed no conflicts of interest.

The United States can end hepatitis B and C transmission and prevent related morbidity and mortality given enough time, resources, and will to surmount a variety of barriers, according to a new report from the National Academies of Sciences, Engineering, and Medicine.

A more feasible short-term goal is to control viral hepatitis by reducing the incidence and prevalence of hepatitis B (HBV) and C virus (HCV) infections, states the report, which is the first of a two-phase study. The second part, to be published in early 2017, will outline a strategy to achieve the goals.

“Disease elimination” once meant stopping all new infections in a population, but eliminating a public health problem “can be a less absolute goal,” Dr. Brian Strom, chancellor of Rutgers Biomedical and Health Sciences, wrote along with his associates. “The WHO has accepted a non-zero target in its work against viral hepatitis,” they added. “The organization’s provisional target is a 90% reduction in incidence, and a 65% reduction in mortality by 2030.”

Furthermore, those are global targets – countries should base their own strategies on their specific viral hepatitis disease burdens and epidemiologic features, Dr. Strom and his associates emphasized. For example, universal vaccination could eradicate HBV in the United States in two generations, but there is no cure for the 700,000-1.4 million Americans who are already infected. Mother-to-child HBV transmission is rare here, but better screening and surveillance could help prevent the 800-1,000 cases of vertical transmission that still occur annually.

More than a third of newborns in the United States do not receive the HBV vaccination on the day they are born, and 28% remain unvaccinated when they are 3 days old, “but childhood catch-up is possible,” the experts also wrote. Vaccinating adults is more complicated, but targeting high-risk groups such as prison inmates or patients at sexually transmitted disease clinics might work, they added. Vaccination is especially important, because chronically infected HBV patients need lifelong medical follow-up to prevent progression and death from cirrhosis and liver cancer, they emphasized.

The hepatitis C virus presents a different picture – there is no HCV vaccine, while the novel direct-acting antivirals can theoretically cure nearly all chronic infections. But in reality, high drug costs and the massive burden of undiagnosed HCV mean that only a small fraction of patients can be cured, the authors acknowledged. On an individual basis, the benefits of direct-acting antivirals outweigh the costs of treating genotype 1 HCV and associated morbidity, they add. But on a population level, “eliminating HCV infection would require near universal access to treatment, something that appears infeasible given the current pricing and policy environment.”

Several other barriers also impede progress against HBV and HCV. For example, only five states and two large cities receive enough funding for comprehensive viral hepatitis surveillance, Dr. Strom and his associates noted. If local and state public health departments cannot track infections, they cannot characterize their epidemics. In addition, viral hepatitis remains a source of stigma, adding to fear and avoidance of testing and undermining elimination efforts. Stigma, avoidance, and the fact that HBV and HCV are asymptomatic in the early stages all contribute to a large population of chronically infected patients who do not know their status.

Moreover, many state Medicaid programs will not cover foreigners until they have lived in the United States for 5 years, and the Affordable Care Act does not cover care for short-term residents and undocumented immigrants, the report stated. Newly infected HCV patients tend to have fewer resources, lower educational levels, and more often use injection drugs, making them harder to reach and screen through the health system. “Prisons are a promising venue in which to treat HCV, but treating HCV is expensive for the prison system. The cost of the direct-acting antivirals is high, and the staff time required to manage an inmate in treatment often far exceed the available resources,” the report stated.

The study was sponsored by the Centers for Disease Control and Prevention Office of Viral Hepatitis and the U.S. Department of Health and Human Services Office of Minority Health. The authors disclosed no conflicts of interest.

The United States can end hepatitis B and C transmission and prevent related morbidity and mortality given enough time, resources, and will to surmount a variety of barriers, according to a new report from the National Academies of Sciences, Engineering, and Medicine.

A more feasible short-term goal is to control viral hepatitis by reducing the incidence and prevalence of hepatitis B (HBV) and C virus (HCV) infections, states the report, which is the first of a two-phase study. The second part, to be published in early 2017, will outline a strategy to achieve the goals.

“Disease elimination” once meant stopping all new infections in a population, but eliminating a public health problem “can be a less absolute goal,” Dr. Brian Strom, chancellor of Rutgers Biomedical and Health Sciences, wrote along with his associates. “The WHO has accepted a non-zero target in its work against viral hepatitis,” they added. “The organization’s provisional target is a 90% reduction in incidence, and a 65% reduction in mortality by 2030.”

Furthermore, those are global targets – countries should base their own strategies on their specific viral hepatitis disease burdens and epidemiologic features, Dr. Strom and his associates emphasized. For example, universal vaccination could eradicate HBV in the United States in two generations, but there is no cure for the 700,000-1.4 million Americans who are already infected. Mother-to-child HBV transmission is rare here, but better screening and surveillance could help prevent the 800-1,000 cases of vertical transmission that still occur annually.

More than a third of newborns in the United States do not receive the HBV vaccination on the day they are born, and 28% remain unvaccinated when they are 3 days old, “but childhood catch-up is possible,” the experts also wrote. Vaccinating adults is more complicated, but targeting high-risk groups such as prison inmates or patients at sexually transmitted disease clinics might work, they added. Vaccination is especially important, because chronically infected HBV patients need lifelong medical follow-up to prevent progression and death from cirrhosis and liver cancer, they emphasized.

The hepatitis C virus presents a different picture – there is no HCV vaccine, while the novel direct-acting antivirals can theoretically cure nearly all chronic infections. But in reality, high drug costs and the massive burden of undiagnosed HCV mean that only a small fraction of patients can be cured, the authors acknowledged. On an individual basis, the benefits of direct-acting antivirals outweigh the costs of treating genotype 1 HCV and associated morbidity, they add. But on a population level, “eliminating HCV infection would require near universal access to treatment, something that appears infeasible given the current pricing and policy environment.”

Several other barriers also impede progress against HBV and HCV. For example, only five states and two large cities receive enough funding for comprehensive viral hepatitis surveillance, Dr. Strom and his associates noted. If local and state public health departments cannot track infections, they cannot characterize their epidemics. In addition, viral hepatitis remains a source of stigma, adding to fear and avoidance of testing and undermining elimination efforts. Stigma, avoidance, and the fact that HBV and HCV are asymptomatic in the early stages all contribute to a large population of chronically infected patients who do not know their status.

Moreover, many state Medicaid programs will not cover foreigners until they have lived in the United States for 5 years, and the Affordable Care Act does not cover care for short-term residents and undocumented immigrants, the report stated. Newly infected HCV patients tend to have fewer resources, lower educational levels, and more often use injection drugs, making them harder to reach and screen through the health system. “Prisons are a promising venue in which to treat HCV, but treating HCV is expensive for the prison system. The cost of the direct-acting antivirals is high, and the staff time required to manage an inmate in treatment often far exceed the available resources,” the report stated.

The study was sponsored by the Centers for Disease Control and Prevention Office of Viral Hepatitis and the U.S. Department of Health and Human Services Office of Minority Health. The authors disclosed no conflicts of interest.