Last data update: May 06, 2024. (Total: 46732 publications since 2009)
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Use of hepatitis B vaccination for adults with diabetes mellitus: recommendations of the Advisory Committee on Immunization Practices (ACIP)
Centers for Disease Control and Prevention , Sawyer MH , Hoerger TJ , Murphy TV , Schillie SF , Hu D , Spradling PR , Byrd KK , Xing J , Reilly ML , Tohme RA , Moorman A , Smith EA , Baack BN , Jiles RB , Klevens M , Ward JW , Kahn HS , Zhou F . MMWR Morb Mortal Wkly Rep 2011 60 (50) 1709-11 Hepatitis B virus (HBV) causes acute and chronic infection of the liver leading to substantial morbidity and mortality. In the United States, since 1996, a total of 29 outbreaks of HBV infection in one or multiple long-term-care (LTC) facilities, including nursing homes and assisted-living facilities, were reported to CDC; of these, 25 involved adults with diabetes receiving assisted blood glucose monitoring. These outbreaks prompted the Hepatitis Vaccines Work Group of the Advisory Committee on Immunization Practices (ACIP) to evaluate the risk for HBV infection among all adults with diagnosed diabetes. The Work Group reviewed HBV infection-related morbidity and mortality and the effectiveness of implementing infection prevention and control measures. The strength of scientific evidence regarding protection was evaluated using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology,* and safety, values, and cost-effectiveness were incorporated into a recommendation using the GRADE system. Based on the Work Group findings, on October 25, 2011, ACIP recommended that all previously unvaccinated adults aged 19 through 59 years with diabetes mellitus (type 1 and type 2) be vaccinated against hepatitis B as soon as possible after a diagnosis of diabetes is made (recommendation category A). Data on the risk for hepatitis B among adults aged ≥60 years are less robust. Therefore, ACIP recommended that unvaccinated adults aged ≥60 years with diabetes may be vaccinated at the discretion of the treating clinician after assessing their risk and the likelihood of an adequate immune response to vaccination (recommendation category B). This report summarizes these recommendations and provides the rationale used by ACIP to inform their decision making. |
Hepatitis C in pregnancy and the TiP-HepC registry
Gupta N , Hiebert L , Armstrong PA , Wester C , Ward JW . Lancet Gastroenterol Hepatol 2022 7 (7) 598-599 Over a fifth of hepatitis C virus (HCV) infections occur in women of childbearing age. 1 At least 19 countries, including the USA, have policies or guidelines recommending universal HCV screening during pregnancy. 2 However, options for management and treatment of HCV infection during pregnancy are not well defined. Typical clinical practice is to refer and link pregnant individuals for treatment after pregnancy and the breastfeeding period; however, in practice, very few are successfully treated. 3 Despite an excellent safety profile, direct-acting antivirals (DAAs) are not recommended for use in pregnancy. To date, only one prospective clinical trial has been published assessing HCV treatment in pregnancy. 4 |
Launch of the Coalition for Global Hepatitis Elimination: a recommendation of the Lancet Gastroenterology & Hepatology Commission
Ward JW , Wiktor SZ , Cooke GS . Lancet Gastroenterol Hepatol 2019 5 (1) 8-10 In response to a recent Lancet Gastroenterology & Hepatology Commission, The Task Force for Global Health launched the Coalition for Global Hepatitis Elimination (CGHE) (1). Modelled after other disease elimination initiatives managed by the Task Force, CGHE strengthens the capacity of national and sub-national hepatitis elimination programs through advocacy, technical assistance, knowledge generation and dissemination among partners united in a community of practice. CGHE is accessible at www.globalhepatitiselimination.org. | A CGHE is needed for several reasons. Viral hepatitis is a large global health threat causing an estimated 1.4 million deaths per year. Of these deaths, 95 % are the result of chronic hepatitis B virus (HBV) and hepatitis C virus (HCV) infection and associated cirrhosis and liver cancer (2). Approximately 325 million persons are living with HBV or HCV infection and an estimated 2.8 million new chronic infections occur annually (2). |
Deaths associated with hepatitis C virus infection among residents in 50 states and the District of Columbia, 2016-2017
Ly KN , Minino AM , Liu SJ , Roberts H , Hughes EM , Ward JW , Jiles RB . Clin Infect Dis 2019 71 (5) 1149-1160 BACKGROUND: Hepatitis C virus (HCV)-associated mortality is well-documented nationally, but examination across regions and jurisdictions may inform healthcare planning. METHODS: To document HCV-associated deaths sub-nationally, we calculated age-adjusted HCV-associated death rates, compared death rate ratios (DRR) for ten US regions, 50 states, and District of Columbia (DC) with the national rate and described rate changes between 2016 and 2017 to determine variability. We examined mean age at HCV-associated death and rates and proportions by sex, race/ethnicity, and birth year. RESULTS: In 2017, there were 17,253 HCV-associated deaths, representing 4.13 (95% CI, 4.07-4.20) deaths/100,000 standard population, a significant 6.56% rate decline from 4.42 in 2016. Age-adjusted death rates significantly surpassed the US rate for the following jurisdictions: Oklahoma, DC, Oregon, New Mexico, Louisiana, Texas, Colorado, California, Kentucky, Tennessee, Arizona, and Washington (DRR, 2.87, 2.77, 2.24, 1.62, 1.57, 1.46, 1.36, 1.35, 1.35, 1.35, 1.32, 1.32, respectively) (P<0.05). Death rates ranged from a low of 1.60 (95% CI, 1.07-2.29) in Maine to a high of 11.84 (95% CI, 10.82-12.85) in Oklahoma. Death rates were highest among non-Hispanic American Indians/Alaska Natives and non-Hispanic blacks nationally and regionally. Mean age at death was 61.4 years (range, 56.6 years in West Virginia to 64.1 years in DC); 78.6% of deaths were born during 1945-1965. CONCLUSION: In 2016-2017, national HCV-associated mortality declined but remained high in western and southern regions, DC, non-Hispanic American Indians/Alaska Natives, non-Hispanic blacks, and Baby Boomers. These data can inform local prevention and control programs to reduce the HCV mortality burden. |
Cost-effectiveness of scaling up HCV prevention and treatment in the United States for people who inject drugs
Barbosa C , Fraser H , Hoerger TJ , Leib A , Havens JR , Young A , Kral A , Page K , Evans J , Zibbell J , Hariri S , Vellozzi C , Nerlander L , Ward JW , Vickerman P . Addiction 2019 114 (12) 2267-2278 AIMS: To examine the cost-effectiveness of hepatitis C (HCV) treatment of people who inject drugs (PWID), combined with medication-assisted treatment (MAT) and syringe-service programs (SSP), to tackle the increasing HCV epidemic in the United States. DESIGN: HCV-transmission and disease progression models with cost-effectiveness analysis using a health care perspective. SETTING: Rural Perry County, Kentucky (PC), and urban San Francisco, California (SF),USA. Compared with PC, SF has a greater proportion of PWID with access to MAT or SSP. HCV treatment of PWID is negligible in both settings. PARTICIPANTS: PWID, data collected between 1998 and 2015 from Social Networks Among Appalachian People, U Find Out, Urban Health Study, and National HIV Behavioral Surveillance System studies. INTERVENTIONS AND COMPARATOR: Three intervention scenarios modeled: baseline-existing SSP and MAT coverage with HCV screening and treatment with direct-acting antiviral for ex-injectors only as per standard of care; Intervention 1-scale-up of SSP and MAT without changes to treatment; and Intervention 2-scale-up as Intervention 1 combined with HCV screening and treatment for current PWID. MEASUREMENTS: Incremental cost-effectiveness ratios (ICERs) and uncertainty using cost-effectiveness acceptability curves. Benefits were measured in quality-adjusted life-years (QALYs). FINDINGS: For both settings, Intervention 2 is preferred to Intervention 1 and the appropriate comparator for Intervention 2 is the baseline scenario. Relative to baseline, for PC Intervention 2 averts 1,852 more HCV infections, increases QALYS by 3,095, costs $21.6 million more, and has an ICER of $6,975/QALY. For SF, Intervention 2 averts 36,473 more HCV infections, increases QALYs by 78,93, costs $ 872 million more, and has an ICER of $11,044/QALY. The cost-effectiveness of Intervention 2 was robust to several sensitivity analysis. CONCLUSIONS: Hepatitis C screening and treatment for people who inject drugs, combined with medication-assisted treatment and syringe-service programs, is a cost-effective strategy for reducing hepatitis C burden in the United States. |
Scaling-up hepatitis C prevention and treatment interventions for achieving elimination in the United States - a rural and urban comparison
Fraser H , Vellozzi C , Hoerger TJ , Evans JL , Kral AH , Havens J , Young AM , Stone J , Handanagic S , Hariri S , Barbosa C , Hickman M , Leib A , Martin NK , Nerlander L , Raymond HF , Page K , Zibbell J , Ward JW , Vickerman P . Am J Epidemiol 2019 188 (8) 1539-1551 In the U.S. Hepatitis C virus (HCV) transmission is increasing among people who inject drugs (PWID). Many regions have insufficient prevention intervention coverage. Using modelling, we investigate the impact of scaling-up prevention and treatment interventions on HCV transmission among PWID in Perry County, Kentucky (PC), and San Francisco, California (SF), where HCV sero-prevalence among PWID is >50%. A greater proportion of PWID access medication-assisted treatment (MAT) or syringe service programs (SSP) in urban SF (established community) than rural PC (young, expanding community). We model the proportion of HCV-infected PWID needing HCV-treatment annually to reduce HCV-incidence by 90% by 2030, with and without MAT scale-up (50% coverage, both settings) and SSP scale-up (PC only) from 2017. With current MAT&SSP coverage during 2017-2030, HCV-incidence will increase in PC (21.3 to 22.6 per 100 person-years (/100pyrs)) and decrease in SF (12.9 to 11.9/100pyrs). With concurrent MAT&SSP scale-up, 5%/year of HCV-infected PWID need HCV-treatment in PC to achieve incidence targets; 13%/year without MAT&SSP scale-up. In SF, a similar proportion need HCV-treatment (10%/year) irrespective of MAT scale-up. Reaching the same impact by 2025 requires increases in treatment rates of 45-82%. Achievable provision of HCV-treatment, alongside MAT&SSP scale-up (PC) and MAT scale-up (SF), could reduce HCV-incidence. |
Accelerating the elimination of viral hepatitis: a Lancet Gastroenterology & Hepatology Commission
Cooke GS , Andrieux-Meyer I , Applegate TL , Atun R , Burry JR , Cheinquer H , Dusheiko G , Feld JJ , Gore C , Griswold MG , Hamid S , Hellard ME , Hou J , Howell J , Jia J , Kravchenko N , Lazarus JV , Lemoine M , Lesi OA , Maistat L , McMahon BJ , Razavi H , Roberts TR , Simmons B , Sonderup MW , Spearman CW , Taylor BE , Thomas DL , Waked I , Ward JW , Wiktor SZ . Lancet Gastroenterol Hepatol 2019 4 (2) 135-184 Viral hepatitis is a major public health threat and a leading cause of death worldwide. Annual mortality from viral hepatitis is similar to that of other major infectious diseases such as HIV and tuberculosis. Highly effective prevention measures and treatments have made the global elimination of viral hepatitis a realistic goal, endorsed by all WHO member states. Ambitious targets call for a global reduction in hepatitis-related mortality of 65% and a 90% reduction in new infections by 2030. This Commission draws together a wide range of expertise to appraise the current global situation and to identify priorities globally, regionally, and nationally needed to accelerate progress. We identify 20 heavily burdened countries that account for over 75% of the global burden of viral hepatitis. Key recommendations include a greater focus on national progress towards elimination with support given, if necessary, through innovative financing measures to ensure elimination programmes are fully funded by 2020. In addition to further measures to improve access to vaccination and treatment, greater attention needs to be paid to access to affordable, high-quality diagnostics if testing is to reach the levels needed to achieve elimination goals. Simplified, decentralised models of care removing requirements for specialised prescribing will be required to reach those in need, together with sustained efforts to tackle stigma and discrimination. We identify key examples of the progress that has already been made in many countries throughout the world, demonstrating that sustained and coordinated efforts can be successful in achieving the WHO elimination goals. |
What is needed to eliminate hepatitis B virus and hepatitis C virus as global health threats
Ward JW , Hinman AR . Gastroenterology 2018 156 (2) 297-310 Hepatitis B virus (HBV) and hepatitis C virus (HCV) cause 1.3 million deaths annually. To prevent over 7 million deaths by 2030, the World Health Organization set goals to eliminate HBV and HCV, defined as a 90% reduction in new infections and a 65% reduction in deaths, and prevent more than 7 million related deaths by 2030. Elimination of HBV and HCV is feasible because of characteristics of the viruses, reliable diagnostic tools, and available cost-effective or cost-saving interventions. Broad implementation of infant immunization against HBV, blood safety and infection-control programs have greatly reduced the burden of HBV and HCV infections. To achieve elimination, priorities include implementation of HBV vaccine-based strategies to prevent perinatal transmission, safe injection practices and HCV treatment for persons who inject drugs, and testing and treatment for HBV- and HCV-infected persons. With sufficient capacity, HBV and HCV elimination programs can meet their goals. |
Estimating prevalence of hepatitis C virus infection in the United States, 2013-2016
Hofmeister MG , Rosenthal EM , Barker LK , Rosenberg ES , Barranco MA , Hall EW , Edlin BR , Mermin J , Ward JW , Blythe Ryerson A . Hepatology 2018 69 (3) 1020-1031 Hepatitis C virus (HCV) infection is the most commonly reported bloodborne infection in the United States, causing substantial morbidity and mortality and costing billions of dollars annually. To update the estimated HCV prevalence among all adults aged >/=18 years in the United States, we analyzed 2013-2016 data from the National Health and Nutrition Examination Survey (NHANES) to estimate the prevalence of HCV in the noninstitutionalized civilian population and used a combination of literature reviews and population size estimation approaches to estimate the HCV prevalence and population sizes for four additional populations: incarcerated people, unsheltered homeless people, active-duty military personnel, and nursing home residents. We estimated that during 2013-2016 1.7% (95% confidence interval [CI], 1.4-2.0%) of all adults in the United States, approximately 4.1 (3.4-4.9) million persons, were HCV antibody-positive (indicating past or current infection) and that 1.0% (95% CI, 0.8-1.1%) of all adults, approximately 2.4 (2.0-2.8) million persons, were HCV RNA-positive (indicating current infection). This includes 3.7 million noninstitutionalized civilian adults in the United States with HCV antibodies and 2.1 million with HCV RNA and an estimated 0.38 million HCV antibody-positive persons and 0.25 million HCV RNA-positive persons not part of the 2013-2016 NHANES sampling frame. Conclusion: Over 2 million people in the United States had current HCV infection during 2013-2016; compared to past estimates based on similar methodology, HCV antibody prevalence may have increased, while RNA prevalence may have decreased, likely reflecting the combination of the opioid crisis, curative treatment for HCV infection, and mortality among the HCV-infected population; efforts on multiple fronts are needed to combat the evolving HCV epidemic, including increasing capacity for and access to HCV testing, linkage to care, and cure. |
Update: Recommendations of the Advisory Committee on Immunization Practices for use of hepatitis A vaccine for postexposure prophylaxis and for preexposure prophylaxis for international travel
Nelson NP , Link-Gelles R , Hofmeister MG , Romero JR , Moore KL , Ward JW , Schillie SF . MMWR Morb Mortal Wkly Rep 2018 67 (43) 1216-1220 Postexposure prophylaxis (PEP) with hepatitis A (HepA) vaccine or immune globulin (IG) effectively prevents infection with hepatitis A virus (HAV) when administered within 2 weeks of exposure. Preexposure prophylaxis against HAV infection through the administration of HepA vaccine or IG provides protection for unvaccinated persons traveling to or working in countries that have high or intermediate HAV endemicity. The Advisory Committee on Immunization Practices (ACIP) Hepatitis Vaccines Work Group conducted a systematic review of the evidence for administering vaccine for PEP to persons aged >40 years and reviewed the HepA vaccine efficacy and safety in infants and the benefits of protection against HAV before international travel. The February 21, 2018, ACIP recommendations update and supersede previous ACIP recommendations for HepA vaccine for PEP and for international travel. Current recommendations include that HepA vaccine should be administered to all persons aged >/=12 months for PEP. In addition to HepA vaccine, IG may be administered to persons aged >40 years depending on the provider's risk assessment. ACIP also recommended that HepA vaccine be administered to infants aged 6-11 months traveling outside the United States when protection against HAV is recommended. The travel-related dose for infants aged 6-11 months should not be counted toward the routine 2-dose series. The dosage of IG has been updated where applicable (0.1 mL/kg). HepA vaccine for PEP provides advantages over IG, including induction of active immunity, longer duration of protection, ease of administration, and greater acceptability and availability. |
Cost effectiveness of universal screening for HCV infection in the era of direct-acting, pangenotypic treatment regimens
Eckman MH , Ward JW , Sherman KE . Clin Gastroenterol Hepatol 2018 17 (5) 930-939 e9 BACKGROUND & AIMS: Most persons infected with hepatitis C virus (HCV) in the United States (US) were born from 1945 through 1965-testing is recommended for this cohort. However, HCV incidence is increasing among younger persons in many parts of the country and treatment is recommended for all adults with HCV infection. We aimed to estimate the cost effectiveness of universal 1-time screening for HCV infection in all adults living in the US and to determine the prevalence of HCV antibody above which HCV testing is cost-effective. METHODS: We developed a Markov state transition model to estimate the effects of universal, 1-time screening of adults 18 years or older in the US, compared with the current guideline-based strategy of screening adults born from 1945 through 1965. We compared potential outcomes of 1-time universal screening of adults or birth cohort screening followed by antiviral treatment of those with HCV infection vs no screening. We measured effectiveness with quality-adjusted life years (QALY), and costs with 2017 US dollars. RESULTS: Based on our model, universal 1-time screening of US residents with general population prevalence of HCV antibody greater than 0.07% cost less than $50,000/QALY compared with a strategy of no screening. Compared with 1-time birth cohort screening, universal 1-time screening and treatment cost $11,378/QALY gained. Universal screening was cost-effective compared with birth cohort screening when the prevalence of HCV antibody positivity was greater than 0.07% among adults not in the cohort born from 1945 through 1965. CONCLUSION: Using a Markov state transition model, we found a strategy of universal 1-time screening for chronic HCV infection to be cost-effective compared with either no screening or birth cohort-based screening alone. |
Hepatitis C in injection-drug users - a hidden danger of the opioid epidemic
Liang TJ , Ward JW . N Engl J Med 2018 378 (13) 1169-1171 Much has been written about the escalating crisis of opioid-overdose deaths in the United States and its mounting social and economic costs. Although political and public health leaders have begun to confront this urgent problem, hidden beneath it lies another danger: the increasing spread of hepatitis C virus (HCV) associated with injection-opioid use. | | The discovery and understanding of HCV and its complications and the recent development of highly effective treatments with cure rates of greater than 90% are triumphs of modern medicine. But this success has fostered a false sense of security: a “curable” disease is deemed a “conquered” disease that no longer warrants high-priority investment. Opioid-related HCV infection and its sequelae, however, affect growing numbers of people. |
Prevention of hepatitis B virus infection in the United States: Recommendations of the Advisory Committee on Immunization Practices
Schillie S , Vellozzi C , Reingold A , Harris A , Haber P , Ward JW , Nelson NP . MMWR Recomm Rep 2018 67 (1) 1-31 Hepatitis B virus (HBV) is transmitted via blood or sexual contact. Persons with chronic HBV infection are at increased risk for cirrhosis and liver cancer and require medical care. This report updates and summarizes previously published recommendations from the Advisory Committee on Immunization Practices (ACIP) and CDC regarding the prevention of HBV infection in the United States. ACIP recommends testing all pregnant women for hepatitis B surface antigen (HBsAg), and testing HBsAg-positive pregnant women for hepatitis B virus deoxyribonucleic acid (HBV DNA); administration of HepB vaccine and hepatitis B immune globulin (HBIG) for infants born to HBV-infected women within 12 hours of birth, followed by completion of the vaccine series and postvaccination serologic testing; universal hepatitis B vaccination within 24 hours of birth, followed by completion of the vaccine series; and vaccination of children and adolescents aged < 19 years who have not been vaccinated previously. ACIP recommends vaccination of adults at risk for HBV infection, including universal vaccination of adults in settings in which a high proportion have risk factors for HBV infection and vaccination of adults requesting protection from HBV without acknowledgment of a specific risk factor. These recommendations also provide CDC guidance for postexposure prophylaxis following occupational and other exposures. This report also briefly summarizes previously published American Association for the Study of Liver Diseases guidelines for maternal antiviral therapy to reduce perinatal HBV transmission. |
Population level outcomes and cost-effectiveness of expanding the recommendation for age-based hepatitis C testing in the United States
Barocas JA , Tasillo A , Eftekhari Yazdi G , Wang J , Vellozzi C , Hariri S , Isenhour C , Randall L , Ward JW , Mermin J , Salomon JA , Linas BP . Clin Infect Dis 2018 67 (4) 549-556 Background: The U.S. Centers for Disease Control and Prevention and the U.S. Preventive Services Task Force recommend one-time hepatitis C virus (HCV) testing for persons born 1945-1965 and targeted testing for high-risk persons. This strategy targets HCV testing to a prevalent population at high risk for HCV morbidity and mortality, but does not include younger populations with high incidence. To address this gap and improve access to HCV testing, age-based strategies should be considered. Methods: We used a simulation of HCV to estimate the effectiveness and cost-effectiveness of HCV testing strategies: 1) standard of care (SOC) - recommendation for one-time testing for all persons born 1945-1965, 2) recommendation for one-time testing for adults >/=40 years (>/=40 strategy), 3) >/=30 years (>/=30 strategy), and 4) >/=18 years (>/=18 strategy). All strategies assumed targeted testing of high-risk persons. Inputs were derived from national databases, observational cohorts and clinical trials. Outcomes included quality-adjusted life expectancy, costs, and cost-effectiveness. Results: Expanded age-based testing strategies increased U.S. population lifetime case identification and cure rates. Greatest increases were observed in the >/=18 strategy. Compared to the SOC, this strategy resulted in an estimated 256,000 additional infected persons identified and 280,000 additional cures at the lowest cost per QALY gained (ICER = $28,000/QALY). Conclusions: In addition to risk-based testing, one-time HCV testing of persons 18 and older appears to be cost-effective, leads to improved clinical outcomes and identifies more persons with HCV than the current birth cohort recommendations. These findings could be considered for future recommendation revisions. |
Increases in acute hepatitis C virus infection related to a growing opioid epidemic and associated injection drug use, United States, 2004 to 2014
Zibbell JE , Asher AK , Patel RC , Kupronis B , Iqbal K , Ward JW , Holtzman D . Am J Public Health 2017 108 (2) e1-e7 OBJECTIVES: To compare US trends in rates of injection drug use (IDU), specifically opioid injection, with national trends in the incidence of acute HCV infection to assess whether these events correlated over time. METHODS: We calculated the annual incidence rate and demographic and risk characteristics of reported cases of acute HCV infection using surveillance data from 2004 to 2014 and the annual percentage of admissions to substance use disorder treatment facilities reporting IDU for the same time period by type of drug injected and demographic characteristics. We then tested for trends. RESULTS: The annual incidence rate of acute HCV infection increased more than 2-fold (from 0.3 to 0.7 cases/100 000) from 2004 to 2014, with significant increases among select demographic subgroups. Admissions for substance use disorder attributed to injection of heroin and prescription opioid analgesics increased significantly, with an almost 4-fold increase in prescription opioid analgesic injection. Significant increases in opioid injection mirrored those for reported cases of acute HCV infection among demographic subgroups. CONCLUSIONS: These findings strongly suggest that the national increase in acute HCV infection is related to the country's opioid epidemic and associated increases in IDU. (Am J Public Health. Published online ahead of print December 21, 2017: e1-e7. doi:10.2105/AJPH.2017.304132). |
The role of screening and treatment in national progress toward hepatitis C elimination - Georgia, 2015-2016
Nasrullah M , Sergeenko D , Gvinjilia L , Gamkrelidze A , Tsertsvadze T , Butsashvili M , Metreveli D , Sharvadze L , Alkhazashvili M , Shadaker S , Ward JW , Morgan J , Averhoff F . MMWR Morb Mortal Wkly Rep 2017 66 (29) 773-776 Georgia, a country in the Caucasus region of Eurasia, has a high prevalence of hepatitis C virus (HCV) infection. In April 2015, with technical assistance from CDC, Georgia embarked on the world's first program to eliminate hepatitis C, defined as a 90% reduction in HCV prevalence by 2020 (1,2). The country committed to identifying infected persons and linking them to care and curative antiviral therapy, which was provided free of charge through a partnership with Gilead Sciences (1,2). From April 2015 through December 2016, a total of 27,595 persons initiated treatment for HCV infection, among whom 19,778 (71.7%) completed treatment. Among 6,366 persons tested for HCV RNA ≥12 weeks after completing treatment, 5,356 (84.1%) had no detectable virus in their blood, indicative of a sustained virologic response (SVR) and cure of HCV infection. The number of persons initiating treatment peaked in September 2016 at 4,595 and declined during October-December. Broader implementation of interventions that increase access to HCV testing, care, and treatment for persons living with HCV are needed for Georgia to reach national targets for the elimination of HCV. |
Scaling up HCV prevention and treatment interventions in rural USA - model projections for tackling an increasing epidemic
Fraser H , Zibbell J , Hoerger T , Hariri S , Vellozzi C , Martin NK , Kral AH , Hickman M , Ward JW , Vickerman P . Addiction 2017 113 (1) 173-182 BACKGROUND AND AIMS: Effective strategies are needed to address dramatic increases in hepatitis C virus (HCV) infection among people who inject drugs (PWID) in rural settings of the United States (US). We determined the required scale-up of HCV treatment with or without scale-up of HCV prevention interventions to achieve a 90% reduction in HCV chronic prevalence or incidence by 2025 and 2030 in a rural US setting. DESIGN: An ordinary differential equation model of HCV transmission calibrated to HCV epidemiological data obtained primarily from a HIV-outbreak investigation in Indiana. SETTING: Scott County, Indiana (population 24,181), USA, a rural setting with negligible baseline interventions, increasing HCV epidemic since 2010, and 55.3% chronic HCV prevalence amongst PWID in 2015 PARTICIPANTS: PWID MEASUREMENTS: Required annual HCV treatments per 1000 PWID (and initial annual percentage of infections treated) to achieve a 90% reduction in HCV chronic prevalence or incidence by 2025/30, either with or without scaling-up syringe service programs (SSPs) and medication-assisted treatment (MAT) to 50% coverage. Sensitivity analyses considered whether this impact could be achieved without retreatment of reinfections, and whether greater intervention scale-up was required due to the increasing epidemic in this setting. FINDINGS: To achieve a 90% reduction in incidence and prevalence by 2030, without MAT and SSP scale-up, 159 per 1000 PWID (initially 25% of infected PWID) need to be HCV-treated annually. However, with MAT and SSP scaled-up, treatment rates are halved (89 per 1000 annually or 15%). To reach the same target by 2025 with MAT and SSP scaled-up, 121 per 1000 PWID (20%) need treatment annually. These treatment requirements are 3-fold higher than if the epidemic was stable, and the impact targets are unattainable without retreatment. CONCLUSIONS: Combined scale-up of hepatitis C virus (HCV) treatment and prevention interventions is needed to decrease the increasing burden of HCV incidence and prevalence in rural Indiana, USA, by 90% by 2025/30. |
State HCV incidence and policies related to HCV preventive and treatment services for persons who inject drugs - United States, 2015-2016
Campbell CA , Canary L , Smith N , Teshale E , Ryerson AB , Ward JW . MMWR Morb Mortal Wkly Rep 2017 66 (18) 465-469 Hepatitis C is associated with more deaths in the United States than 60 other infectious diseases reported to CDC combined. Despite curative hepatitis C virus (HCV) therapies and known preventive measures to interrupt transmission, new HCV infections have increased in recent years. Injection drug use is the primary risk factor for new HCV infections. One potential strategy to decrease the prevalence of HCV is to create and strengthen public health laws and policies aimed specifically at reducing transmission risks among persons who inject drugs. To evaluate factors affecting access to HCV preventive and treatment services, CDC assessed state laws governing access to safe injection equipment and Medicaid policies related to sobriety requirements for approval of HCV treatment for persons who inject drugs. Acute HCV incidence rates were obtained from CDC's National Notifiable Disease Surveillance System (NNDSS). States were categorized based on analysis of laws related to access to clean needles and syringes and Medicaid HCV treatment policies associated with sobriety requirements. In 2015, HCV incidence remained high in the United States, with rates in 17 states exceeding the national average. Three states were determined to have state laws and Medicaid policies capable of comprehensively preventing and treating HCV among persons who inject drugs. Opportunities exist for states to adopt laws and policies that could help increase access to HCV preventive and treatment services reducing the number of persons at risk for HCV transmission and disease. |
Estimation of state-level prevalence of hepatitis C virus infection, US states and District of Columbia, 2010
Rosenberg ES , Hall EW , Sullivan PS , Sanchez TH , Workowski KA , Ward JW , Holtzman D . Clin Infect Dis 2017 64 (11) 1573-1581 Background.: Hepatitis C virus (HCV) infection is the most common chronic blood-borne infection in the United States and a leading cause of morbidity and mortality. Previous analyses of the US National Health and Nutrition Examination Survey (NHANES) indicated approximately 3.6 million noninstitutionalized persons with antibody to HCV (anti-HCV). However, state-level prevalence remains less understood and cannot be estimated reliably from NHANES alone. Methods.: We used 3 publicly available government data sources to estimate anti-HCV prevalence in each US state among noninstitutionalized persons aged ≥18 years. A small-area estimation model combined indirect standardization of NHANES-based prevalence with logistic regression modeling of mortality data, listing acute or chronic HCV infection as a cause of death, from the National Vital Statistics System during 1999-2012. Model results were combined with US Census population sizes to estimate total number and prevalence of persons with antibody to HCV in 2010. Results.: National anti-HCV prevalence was 1.67% (95% confidence interval [CI], 1.53-1.90), or 3 911 800 (95% CI, 3 589 400- 4 447 500) adults in 2010. State-specific prevalence ranged from 0.71% (Illinois) to 3.34% (Oklahoma). The West census region had the highest region-specific prevalence (2.14% [95% CI, 1.96-2.48]); 10 of 13 states had rates above the national average. The South had the highest number of persons with anti-HCV (n = 1561600 [95% CI, 1 427 700-1 768 900]). The Midwest had the lowest region-specific prevalence (1.14% [95% CI, 1.04%-1.30%]). Conclusions.: States in the US West and South have been most impacted by hepatitis C. Estimates of HCV infection burden are essential to guide policy and programs to optimally prevent, detect, and cure infection. |
County-level vulnerability assessment for rapid dissemination of HIV or HCV infections among persons who inject drugs, United States
Van Handel MM , Rose CE , Hallisey EJ , Kolling JL , Zibbell JE , Lewis B , Bohm MK , Jones CM , Flanagan BE , Siddiqi AE , Iqbal K , Dent AL , Mermin JH , McCray E , Ward JW , Brooks JT . J Acquir Immune Defic Syndr 2016 73 (3) 323-331 OBJECTIVE: A recent HIV outbreak in a rural network of persons who inject drugs (PWID) underscored the intersection of the expanding epidemics of opioid abuse, unsterile injection drug use (IDU), and associated increases in hepatitis C virus (HCV) infections. We sought to identify US communities potentially vulnerable to rapid spread of HIV, if introduced, and new or continuing high rates of HCV infections among PWID. DESIGN: We conducted a multistep analysis to identify indicator variables highly associated with IDU. We then used these indicator values to calculate vulnerability scores for each county to identify which were most vulnerable. METHODS: We used confirmed cases of acute HCV infection reported to the National Notifiable Disease Surveillance System, 2012-2013, as a proxy outcome for IDU, and 15 county-level indicators available nationally in Poisson regression models to identify indicators associated with higher county acute HCV infection rates. Using these indicators, we calculated composite index scores to rank each county's vulnerability. RESULTS: A parsimonious set of 6 indicators were associated with acute HCV infection rates (proxy for IDU): drug-overdose deaths, prescription opioid sales, per capita income, white, non-Hispanic race/ethnicity, unemployment, and buprenorphine prescribing potential by waiver. Based on these indicators, we identified 220 counties in 26 states within the 95th percentile of most vulnerable. CONCLUSIONS: Our analysis highlights US counties potentially vulnerable to HIV and HCV infections among PWID in the context of the national opioid epidemic. State and local health departments will need to further explore vulnerability and target interventions to prevent transmission. |
Global elimination of hepatitis C virus
Ward JW . Gastroenterol Hepatol (N Y) 2016 12 (10) 632-635 JW According to the World Health Organization, the goal is to eliminate hepatitis C virus (HCV) as a public health threat. Specifically, the goal is dramatic and large-scale reductions in new transmissions of HCV, as well as in the number of people becoming ill and dying from HCV, to a level where HCV no longer represents a major health concern. In numeric terms, the World Health Organization has proposed reductions of 60% in HCV-related mortality and 90% in HCV transmission globally and in member countries, including the United States. |
Building the evidence base to eliminate hepatitis B and C as public health threats
Ward JW . Lancet Infect Dis 2016 16 (12) 1314-1316 The rigorous analysis of evidence by Kali Zhou and colleagues1 is a benchmark endeavour that reveals both the evidence-based interventions that improve hepatitis B virus (HBV) and hepatitis C virus (HCV) testing and linkage to care and treatment (ie, the care cascade), and the major remaining gaps in this knowledge base. This analysis arrives at a crucial time for public health. The global burden of viral hepatitis is huge. Over 400 million people have HBV or HCV infection.2 In 2013, about 1·4 million people died of HBV-related or HCV-related liver cancer and other diseases, surpassing deaths from HIV, tuberculosis, and even road injuries.2, 3 Testing with linkage to care and treatment reduces the risk of these health outcomes. For people infected with HBV, treatment that suppresses viral replication reduces the risk of liver cancer by 50%.4 For people with HCV, all-oral therapy cures up to 90% of those infected within 8–12 weeks of therapy.2 HCV treatment lowers the risk of liver cancer by 75% and all-cause mortality by 45%.5, 6 However, availability of testing and effective, even curative therapies, together do not ensure that infected people will have access to and receive the full continuum of services needed to improve health outcomes.7 Indeed, less than 5% of people with HBV or HCV infection are aware they are infected and are receiving recommended care and treatment.2 |
The burden of hepatitis C infection-related liver fibrosis in the United States
Klevens RM , Canary L , Huang X , Denniston MM , Yeo AE , Pesano RL , Ward JW , Holmberg S . Clin Infect Dis 2016 63 (8) 1049-55 BACKGROUND: Knowledge of the estimated proportion of hepatitis C virus (HCV)-infected persons with advanced fibrosis or cirrhosis is critical to estimating healthcare needs. METHODS: We analyzed HCV-related testing conducted by Quest Diagnostics from January 2010 through December 2013. Tests included hepatitis C antibody, HCV RNA, HCV genotype (nucleic acid tests [NAT]), liver function tests, and platelet counts; patient age was also determined. Aspartate aminotransferase (AST)-to-platelet ratio (APRI) was calculated as = 100*(aspartate aminotransferase [AST]/upper limit of AST)/platelet. Fibrosis-4 (FIB-4) was calculated as (age x AST)/(platelet x radical alanine aminotransferase [ALT]). Persons were "currently infected" if they had ≥1 positive HCV NAT; "in care" if a positive RNA test was followed <6 months by ≥1 additional NAT(s), or ALT, AST, and platelets <90 days, or any test ordered by an infectious diseases or gastroenterology specialist; and "evaluated for treatment" if they had a genotype test. RESULTS: Approximately 10 million HCV test results were analyzed, representing 5.6 million unique patients. Of the 2.6 million patients with data to estimate liver disease, 5% were currently infected. Among those currently infected, APRI and FIB-4 scores indicated that 23% overall-and 27% among the cohort born during 1945-1965-had advanced fibrosis or cirrhosis at first diagnosis. A total of 54% of infected were in care and 51% of infected with advanced fibrosis or cirrhosis were evaluated for treatment. CONCLUSIONS: Testing from a large US commercial laboratory indicates that about 1 in 4 HCV-infected persons have levels of liver disease put them at highest risk for complications and could benefit from immediate antiviral therapy. |
Increased hepatitis C virus (HCV) detection in women of childbearing age and potential risk for vertical transmission - United States and Kentucky, 2011-2014
Koneru A , Nelson N , Hariri S , Canary L , Sanders KJ , Maxwell JF , Huang X , Leake JA , Ward JW , Vellozzi C . MMWR Morb Mortal Wkly Rep 2016 65 (28) 705-710 Hepatitis C virus (HCV) infection is a leading cause of liver-related morbidity and mortality (1). Transmission of HCV is primarily via parenteral blood exposure, and HCV can be transmitted vertically from mother to child. Vertical transmission occurs in 5.8% (95% confidence interval = 4.2%-7.8%) of infants born to women who are infected only with HCV and in up to twice as many infants born to women who are also infected with human immunodeficiency virus (HIV) (2) or who have high HCV viral loads (3,4); there is currently no recommended intervention to prevent transmission of infection from mother to child (3). Increased reported incidence of HCV infection among persons aged ≤30 years (5,6) with similar increases among women and men in this age group (6), raises concern about increases in the number of pregnant women with HCV infection, and in the number of infants who could be exposed to HCV at birth. Data from one large commercial laboratory and birth certificate data were used to investigate trends in HCV detection among women of childbearing age,* HCV testing among children aged ≤2 years, and the proportions of infants born to HCV-infected women nationally and in Kentucky, the state with the highest incidence of acute HCV infection during 2011-2014 (6). During 2011-2014, commercial laboratory data indicated that national rates of HCV detection (antibody or RNA positivitydagger) among women of childbearing age increased 22%, and HCV testing (antibody or RNA) among children aged ≤2 years increased 14%; birth certificate data indicated that the proportion of infants born to HCV-infected mothers increased 68%, from 0.19% to 0.32%. During the same time in Kentucky, the HCV detection rate among women of childbearing age increased >200%, HCV testing among children aged ≤2 years increased 151%, and the proportion of infants born to HCV-infected women increased 124%, from 0.71% to 1.59%. Increases in the rate of HCV detection among women of childbearing age suggest a potential risk for vertical transmission of HCV. These findings highlight the importance of following current CDC recommendations to identify, counsel, and test persons at risk for HCV infection (1,7), including pregnant women, as well as consider developing public health policies for routine HCV testing of pregnant women, and expanding current policies for testing and monitoring children born to HCV-infected women. Expansion of HCV reporting and surveillance requirements will enhance case identification and prevention strategies. |
Identification and clinical management of persons with chronic hepatitis C virus infection - Cherokee Nation, 2012-2015
Mera J , Vellozzi C , Hariri S , Carabin H , Drevets DA , Miller A , Reilley B , Essex W , Gahn D , Lyons L , Leston J , Ward JW . MMWR Morb Mortal Wkly Rep 2016 65 (18) 461-6 An estimated 3.5 million persons in the United States are living with hepatitis C virus (HCV) infection, resulting in approximately 20,000 deaths each year, primarily from cirrhosis or hepatocellular carcinoma (1,2). American Indian/Alaska Native (AI/AN) populations have the highest incidence of acute HCV infection among all U.S. racial/ethnic groups and are at greater risk for HCV-related mortality compared with the general population (3). In 2013, new antiviral drugs became available that make possible 8-12 week treatment regimens with fewer adverse events and are able to achieve sustained virologic response (SVR) in >90% of treated patients (4), equivalent to a cure of HCV infection. Also of note, HCV testing recommendations were expanded in 2012 by CDC and in 2013 by the U.S. Preventive Services Task Force to include one-time testing of persons born during 1945-1965 (the "baby boomer" cohort) in addition to anyone at increased risk for HCV infection (5,6). Given the availability of new HCV drugs, expanded testing recommendations, and high incidence of HCV infection in AI/AN populations, in October 2012, Cherokee Nation Health Services (CNHS) implemented a tribal HCV testing policy.* As part of the policy, CNHS added a reminder in the electronic health record (EHR) for clinical decision support and provided HCV education to primary care clinicians. From October 2012 to July 2015, among 92,012 persons with at least one CNHS clinic encounter, the cumulative number who received HCV screening for the first time increased from 3,337 (3.6%) to 16,772 (18.2%). The largest percentage of HCV screening was among persons born during 1945-1965. Of 715 persons who tested positive for HCV antibodies, 488 (68.3%) were tested for HCV RNA; among those 488 persons, 388 (79.5%) were RNA positive and were thus confirmed to have chronic HCV infection. Treatment was initiated for 223 (57.5%) of the 388 with chronic infection; 201 (90.1%) completed treatment, of whom 180 (89.6%) achieved SVR. CNHS has successfully increased HCV testing and treatment and is now collaborating with CDC and other external partners to develop an HCV elimination program for the Cherokee Nation that might serve as a model for similar settings. |
Strategies for expanding access to HBV and HCV testing and care in the United States: The CDC Hepatitis Testing and Linkage to Care Initiative, 2012-2014
Ward JW . Public Health Rep 2016 131 1-4 As many as 5.7 million people in the United States are living with hepatitis B virus (HBV) or hepatitis C virus (HCV) infection.1,2 Both infections are leading causes of liver cancer and infectious disease-related mortality.3 Therapies are available to suppress replication of HBV and eliminate or cure HCV infection, thereby dramatically decreasing the risk for liver cancer and death associated with these infections. However, at least half of the people living with HCV infection are unaware of their infection.4 Because most infected people develop few or no symptoms or signs of infection until their liver disease is far advanced, testing people for HBV and HCV is the critical first step toward identifying infected people and linking them to recommended care and treatment. As such, preventing HBV- and HCV-associated morbidity and mortality hinges on identifying effective testing strategies. | In 2011, the U.S. Department of Health and Human Services (HHS) released an action plan with goals for increasing the number of people living with HBV or HCV infection who are aware of their infection.5 Guided by the HHS action plan, the U.S. Centers for Disease Control and Prevention (CDC) developed the Hepatitis Testing and Linkage to Care (HepTLC) initiative to implement the agency's recommendations for HBV and HCV testing.4,6 In 2012, CDC received an appropriation from the Prevention and Public Health Fund (PPHF) for improvements in HBV and HCV testing. The PPHF is the nation's first mandatory funding stream dedicated to improving the U.S. public health system.7 With these funds, the U.S. Senate directed the CDC Division of Viral Hepatitis to increase the number of HBV- and HCV-infected people who are aware of their infection and receiving care.8 In 2013, CDC received resources from HHS to extend the PPHF-supported projects for another year. |
The spread of hepatitis C virus genotype 1a in North America: a retrospective phylogenetic study.
Joy JB , McCloskey RM , Nguyen T , Liang RH , Khudyakov Y , Olmstead A , Krajden M , Ward JW , Harrigan PR , Montaner JS , Poon AF . Lancet Infect Dis 2016 16 (6) 698-702 BACKGROUND: The timing of the initial spread of hepatitis C virus genotype 1a in North America is controversial. In particular, how and when hepatitis C virus reached extraordinary prevalence in specific demographic groups remains unclear. We quantified, using all available hepatitis C virus sequence data and phylodynamic methods, the timing of the spread of hepatitis C virus genotype 1a in North America. METHODS: We screened 45 316 publicly available sequences of hepatitis C virus genotype 1a for location and genotype, and then did phylogenetic analyses of available North American sequences from five hepatitis C virus genes (E1, E2, NS2, NS4B, NS5B), with an emphasis on including as many sequences with early collection dates as possible. We inferred the historical population dynamics of this epidemic for all five gene regions using Bayesian skyline plots. FINDINGS: Most of the spread of genotype 1a in North America occurred before 1965, and the hepatitis C virus epidemic has undergone relatively little expansion since then. The effective population size of the North American epidemic stabilised around 1960. These results were robust across all five gene regions analysed, although analyses of each gene separately show substantial variation in estimates of the timing of the early exponential growth, ranging roughly from 1940 for NS2, to 1965 for NS4B. INTERPRETATION: The expansion of genotype 1a before 1965 suggests that nosocomial or iatrogenic factors rather than past sporadic behavioural risk (ie, experimentation with injection drug use, unsafe tattooing, high risk sex, travel to high endemic areas) were key contributors to the hepatitis C virus epidemic in North America. Our results might reduce stigmatisation around screening and diagnosis, potentially increasing rates of screening and treatment for hepatitis C virus. FUNDING: The Canadian Institutes of Health Research, Michael Smith Foundation for Health Research, and BC Centre for Excellence in HIV/AIDS. |
Annual report to the nation on the status of cancer, 1975-2012, featuring the increasing incidence of liver cancer
Ryerson AB , Eheman CR , Altekruse SF , Ward JW , Jemal A , Sherman RL , Henley SJ , Holtzman D , Lake A , Noone AM , Anderson RN , Ma J , Ly KN , Cronin KA , Penberthy L , Kohler BA . Cancer 2016 122 (9) 1312-37 BACKGROUND: Annual updates on cancer occurrence and trends in the United States are provided through an ongoing collaboration among the American Cancer Society (ACS), the Centers for Disease Control and Prevention (CDC), the National Cancer Institute (NCI), and the North American Association of Central Cancer Registries (NAACCR). This annual report highlights the increasing burden of liver and intrahepatic bile duct (liver) cancers. METHODS: Cancer incidence data were obtained from the CDC, NCI, and NAACCR; data about cancer deaths were obtained from the CDC's National Center for Health Statistics (NCHS). Annual percent changes in incidence and death rates (age-adjusted to the 2000 US Standard Population) for all cancers combined and for the leading cancers among men and women were estimated by joinpoint analysis of long-term trends (incidence for 1992-2012 and mortality for 1975-2012) and short-term trends (2008-2012). In-depth analysis of liver cancer incidence included an age-period-cohort analysis and an incidence-based estimation of person-years of life lost because of the disease. By using NCHS multiple causes of death data, hepatitis C virus (HCV) and liver cancer-associated death rates were examined from 1999 through 2013. RESULTS: Among men and women of all major racial and ethnic groups, death rates continued to decline for all cancers combined and for most cancer sites; the overall cancer death rate (for both sexes combined) decreased by 1.5% per year from 2003 to 2012. Overall, incidence rates decreased among men and remained stable among women from 2003 to 2012. Among both men and women, deaths from liver cancer increased at the highest rate of all cancer sites, and liver cancer incidence rates increased sharply, second only to thyroid cancer. Men had more than twice the incidence rate of liver cancer than women, and rates increased with age for both sexes. Among non-Hispanic (NH) white, NH black, and Hispanic men and women, liver cancer incidence rates were higher for persons born after the 1938 to 1947 birth cohort. In contrast, there was a minimal birth cohort effect for NH Asian and Pacific Islanders (APIs). NH black men and Hispanic men had the lowest median age at death (60 and 62 years, respectively) and the highest average person-years of life lost per death (21 and 20 years, respectively) from liver cancer. HCV and liver cancer-associated death rates were highest among decedents who were born during 1945 through 1965. CONCLUSIONS: Overall, cancer incidence and mortality declined among men; and, although cancer incidence was stable among women, mortality declined. The burden of liver cancer is growing and is not equally distributed throughout the population. Efforts to vaccinate populations that are vulnerable to hepatitis B virus (HBV) infection and to identify and treat those living with HCV or HBV infection, metabolic conditions, alcoholic liver disease, or other causes of cirrhosis can be effective in reducing the incidence and mortality of liver cancer. (c) |
Simple, effective, but out of reach? Public health implications of HCV drugs
Ward JW , Mermin JH . N Engl J Med 2015 373 (27) 2678-80 The results of four clinical trials showing the excellent safety and efficacy of a 12-week course of sofosbuvir (an NS5B inhibitor licensed in the United States in 2013) and velpatasvir (a new NS5A inhibitor) in treating patients with hepatitis C infection (HCV) are reported. |
Update: shortened interval for postvaccination serologic testing of infants born to hepatitis B-infected mothers
Schillie S , Murphy TV , Fenlon N , Ko S , Ward JW . MMWR Morb Mortal Wkly Rep 2015 64 (39) 1118-1120 Infants born to hepatitis B-infected mothers receive postexposure prophylaxis to reduce their risk for perinatal hepatitis B virus (HBV) infection. Postexposure prophylaxis consists of hepatitis B (HepB) vaccine and hepatitis B immune globulin administered within 12 hours of birth, followed by completion of the 3-dose or 4-dose HepB vaccine series. Postvaccination serologic testing (PVST) assesses an infant's response to HepB vaccination and has typically occurred at age 9-18 months. This report provides a CDC update recommending shortening the interval for PVST from age 9-18 months to age 9-12 months. Providers should order PVST (consisting of hepatitis B surface antigen [HBsAg] and antibody to HBsAg [anti-HBs]) for infants born to HBsAg-positive mothers at age 9-12 months (or 1-2 months after the final dose of the vaccine series, if the series is delayed). This recommendation was prompted by the discontinuation of production of Hib/HepB vaccine (Comvax) and new data from the Enhanced Perinatal Hepatitis B Prevention Program supporting PVST 1・2 months after receipt of the last HepB vaccine dose, and at age >/=9 months. |
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