David B. Rein

Hepatitis C virus (HCV) is an increasing cause of morbidity and mortality in the United States. Many of the 2.7-3.9 million persons living with HCV infection are unaware they are infected and do not receive care (e.g., education, counseling, and medical monitoring) and treatment. CDC estimates that although persons born during 1945-1965 comprise an estimated 27% of the population, they account for approximately three fourths of all HCV infections in the United States, 73% of HCV-associated mortality, and are at greatest risk for hepatocellular carcinoma and other HCV-related liver disease. With the advent of new therapies that can halt disease progression and provide a virologic cure (i.e., sustained viral clearance following completion of treatment) in most persons, targeted testing and linkage to care for infected persons in this birth cohort is expected to reduce HCV-related morbidity and mortality. CDC is augmenting previous recommendations for HCV testing (CDC. Recommendations for prevention and control of hepatitis C virus (HCV) infection and HCV-related chronic disease. MMWR 1998;47[No. RR-19]) to recommend one-time testing without prior ascertainment of HCV risk for persons born during 1945-1965, a population with a disproportionately high prevalence of HCV infection and related disease. Persons identified as having HCV infection should receive a brief screening for alcohol use and intervention as clinically indicated, followed by referral to appropriate care for HCV infection and related conditions. These recommendations do not replace previous guidelines for HCV testing that are based on known risk factors and clinical indications. Rather, they define an additional target population for testing: persons born during 1945-1965. CDC developed these recommendations with the assistance of a work group representing diverse expertise and perspectives. The recommendations are informed by the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework, an approach that provides guidance and tools to define the research questions, conduct the systematic review, assess the overall quality of the evidence, and determine strength of the recommendations. This report is intended to serve as a resource for health-care professionals, public health officials, and organizations involved in the development, implementation, and evaluation of prevention and clinical services. These recommendations will be reviewed every 5 years and updated to include advances in the published evidence.

Objectives.: Information on the process and method of service delivery is sparse for hepatitis B surface antigen (HBsAg) testing, and no systematic study has evaluated the relative effectiveness or cost-effectiveness of different HBsAg screening models. To address this need, we compared five specific community-based screening programs. Methods.: We funded five HBsAg screening programs to collect information on their design, costs, and outcomes of participants during a six-month observation period. We categorized programs into four types of models. For each model, we calculated the number screened, the number screened as per Centers for Disease Control and Prevention (CDC) recommendations, and the cost per screening. Results.: The models varied by cost per person screened and total number of people screened, but they did not differ meaningfully in the proportion of people screened following CDC recommendations, the proportion of those screened who tested positive, or the proportion of those who newly tested positive. Conclusions.: Integrating screening into outpatient service settings is the most cost-effective method but may not reach all people needing to be screened. Future research should examine cost-effective methods that expand the reach of screening into communities in outpatient settings.

To determine whether biennial eye evaluation or telemedicine screening are cost-effective alternatives to current recommendations for the estimated 10 million people aged 30-84 with diabetes but no or minimal diabetic retinopathy. United Kingdom Prospective Diabetes Study, National Health and Nutrition Examination Survey, American Academy of Ophthalmology Preferred Practice Patterns, Medicare Payment Schedule. Cost-effectiveness Monte Carlo simulation. Literature review, analysis of existing surveys. Biennial eye evaluation was the most cost-effective treatment option when the ability to detect other eye conditions was included in the model. Telemedicine was most cost-effective when other eye conditions were not considered or when telemedicine was assumed to detect refractive error. The current annual eye evaluation recommendation was costly compared with either treatment alternative. Self-referral was most cost-effective up to a willingness to pay (WTP) of U.S.$37,600, with either biennial or annual evaluation most cost-effective at higher WTP levels. Annual eye evaluations are costly and add little benefit compared with either plausible alternative. More research on the ability of telemedicine to detect other eye conditions is needed to determine whether it is more cost-effective than biennial eye evaluation.

The Centers for Disease Control and Prevention recommends hepatitis B surface antigen (HBsAg) testing to identify chronic hepatitis B virus infection for foreign-born persons from countries or regions with HBsAg prevalence of ≥2%. However, limited data exist to indicate which countries meet this definition. To address this data gap, we estimated the HBsAg prevalence among refugees entering the United States between 2006 and 2008. We contacted state refugee health coordinators and asked them to report the number of refugees, country of origin, and HBsAg prevalence among refugees screened in their jurisdiction during the most recently available 12-month period prior to August 2008. We pooled data across jurisdictions and calculated the prevalence for any country with more than 30 refugees entering the United States, and where this level of data was not available by country, continents were considered. Of the 47 jurisdictions contacted, we received basic information from 31, with nine jurisdictions reporting HBsAg prevalence by country of origin applicable to 31,980 refugees (approximately 42% of refugees entering the United States during the observation period). We estimated an HBsAg prevalence of 2.8% (95% confidence interval 2.6%-3.0%) for refugees overall. Of the 37 countries with 30 or more refugees entering the United States, 25 had a prevalence of ≥2%. Prevalence was highest among refugees from Africa and Southeast Asia, and lowest among refugees from the Middle East and South/Central America. In the eight countries for which we had comparison data, six had lower HBsAg prevalence than in 1991. (Hepatology 2009.)

Summary. The Centers for Disease Control and Prevention (CDC) recommends hepatitis B surface antigen (HBsAg) testing to identify hepatitis B virus (HBV) infection for foreign-born persons from areas with HBsAg prevalence of ≥2%. Currently, most HBsAg screening in the United States is performed by independent community organizations. For these HBsAg screening programs, we collected information about the location, number of people screened, other services beyond screening provided, the population/ethnicity groups targeted for screening, and the prevalence of HBsAg among those screened. We identified programs offering screening by contacting programs known to us, from interviews with identified programs, and from structured Internet searches, and collected information using a simple e-mail survey with follow-up phone calls. We identified 55 possible community HBsAg screening programs, of which we successfully contacted 31 programs. In the past year, contacted programs screened an estimated 21 817 patients with an 8.1% average HBsAg prevalence. The majority of programs screened persons born in Asia and their children, and a small number of programs screened persons from Africa or Eastern Europe; very few programs screened U.S.-born persons at risk of HBV infection due to behavioural factors. We identified few or no programs in the American Southeast, the Midwest, and the Southwest outside of California and the Houston area. The HBsAg screening programs that we contacted were effective in identifying and screening patients at risk of HBV as evidenced by the high prevalence observed among those screened. However, their efforts alone are likely insufficient to meet the need for screening recommended by CDC.

Age-related macular degeneration (AMD) is a macular disorder characterized by drusen deposits, retinal pigment epithelium (RPE) abnormalities, geographic atrophy (GA) of the RPE and the choriocapillaris, and neovascular maculopathy.¹In 2000, as many as 1.75 million Americans experienced advanced vision-threatening stages of AMD (choroidal neovascularization [CNV] and GA) and millions more had asymptomatic early disease.²In the United States, AMD is the estimated cause of 54.4% of visual impairment and 22.9% of blindness among white persons. Among Hispanic and black persons, the percentages are smaller but still significant.³The direct medical cost of AMD treatment was estimated at $575 million in the United States in 2004 dollars, excluding nursing home costs, productivity losses, and home health care costs incurred by those with AMD,⁴a cost that is expected to increase with the increased use of new CNV treatments.