​Medscape Medical News:
Pam Harrison, March 23, 2020

Liver cancer rates have been increasing, but a new analysis finds that the increase has occurred primarily in men older than 60 years in developed countries.
The findings come from an analysis of data from the Global Burden of Disease (GBD) Study 2017, published online March 23 in Cancer.

From 1990 to 2017, the number of cancer cases increased nearly threefold in older men and more than twofold in older women (aged 60 years or more). This increase was driven mainly by an increase in liver cancer caused by nonalcoholic steatohepatitis (NASH), also termed fatty liver disease, note the authors.
In contrast, the incidence of liver cancer among men and women who are younger than 30 years and those aged 30 to 59 years declined during this period.

The decreases seen in younger adults were largely ascribed to hepatitis B virus (HBV) vaccination and were consistent in most regions except in developed countries, where liver cancer rates increased irrespective of sex and age.
"Our findings suggest a lack of attention for older people in current liver cancer prevention efforts and highlight the emerging concern of obesity as a risk factor for liver cancer," lead author Xingdong Chen, MD, PhD, Fudan University, China, said in a statement.
"Liver cancer prevention strategies in both developing and developed countries should be tailored and updated," he added.
The authors point out that liver cancer was previously considered to be rare in the Western hemisphere.
"However, we found a significant increase in primary liver cancer incidence —regardless of etiology, sex, or age — in most of these countries over the last few decades," they observe.
The fact that the most pronounced increase in liver cancer was caused by NASH suggests that more attention should be paid to weight management and obesity control as primary prevention strategies in these regions, they suggest.
Study DesignAnnual incidence data were collected from 1990 to 2017 and were categorized by sex, region, country, age group, and etiology.
"Data from a total of 195 countries and territories were available," the investigators note, "and these countries and territories were categorized into 5 regions in terms of sociodemographic index (SDI)," they add.
Data were also retrieved regarding five etiologies of liver cancer: HBV infection, hepatitis C virus (HCV) infection, alcohol use, NASH, and others.
The authors note that age-standardized incidence rates of primary liver cancer caused by those five etiologies increased significantly in Australasia, Western Europe, and high-income regions of North America. The most significant increase was found in liver cancer caused by NASH in the Netherlands (in men) and in Finland (in women).
An increasing trend was observed in most countries for primary liver cancer among people aged 60 years or older, the authors note. They suggest that population expansion, aging, and increasing prevalence of obesity and diabetes might partly explain the marked increase, especially the dramatic increase in the number of cases among older people. Additionally, the "lag effect" of the large HBV infection reservoir in several countries might also contribute to the increase, the authors state. They explain that people infected with HBV early in life may experience progression to liver cancer as they age.
Primary PreventionPrevention of HBV infection — the primary cause of liver cancer — has been possible since the introduction of the HBV vaccine in 1982.
"By the end of 2017, 187 countries had introduced the HBV vaccine into their national immunization schedules, with global coverage with 3 doses of the hepatitis B vaccine...estimated at 84%," the authors point out.
This has "dramatically" reduced both the prevalence of HBV infection and the incidence of liver cancer caused by it among younger people in high-risk countries, they comment.
The investigators also observed a significant decrease in the incidence of liver cancer caused by HBV infection in people aged 30 to 59 years, although the decline was smaller than it was for those younger than 30.
Moreover, HCV infection has emerged as a concerning cause of liver cancer among those who used to be at low risk for HCV infection.
Although there is optimism that global control of HCV infection can be achieved through direct-acting antiviral agents, "the high cost, drug resistance, and reinfection rates are still major obstacles to fulfilling this ambitious goal," Chen and colleagues point out.
TO CONTINUE READING: https://www.medscape.com/viewarticle/927374

On the morning of Friday, March 13th, Mary Beth Appel and Johanna Berrigan, two health-care workers who run a free clinic in North Philadelphia, were preparing for the morning rush. Their clients are experiencing homelessness, and sleep in abandoned buildings, shelters, or on the street nearby. “We see the same things that an urgent-care clinic does,” Appel, a sixty-year-old nurse practitioner, told me. The most common ailments included colds, wounds, chronic illnesses, and some frostbite. Today, though, they were bracing for the arrival of covid-19. “I fully expect we’ll both get it. Don’t you?” Appel asked Berrigan, a sixty-four-year-old physician assistant. The women were seated on the first floor of the clinic, a converted row house, discussing how to contain infection among their clients. “The protocol now, if you feel sick, is go home and isolate,” Berrigan said. “Where are our people going to go? We’re going to isolate them under a tree in the park?”
The health-care clinic is one of two or three in the country that are part of the Catholic Worker Movement, a loose-knit social-justice organization started by Dorothy Day and Peter Maurin, in 1933. Appel and Berrigan had been running the clinic for almost twenty-nine years, and had treated patients through the aids crisis, the crack epidemic, and, more recently, widespread addiction to opioids. They were well-acquainted with the difficulties of meeting human needs during a crisis: Berrigan travelled to Iraq, in the nineties and early two-thousands, to document the impact of economic sanctions on its people, and helped provide care in Haiti in the aftermath of the earthquake that devastated  the island in 2010. Still, they had never seen anything like the coronavirus. When I arrived, Appel had just spoken to a fellow Catholic Worker, in New York, to ask for advice on how to pray for the protection of their patients. “I was looking for the patron saint of spit,” she told me, only half joking. “There is one for bed bugs.”
TO CONTINUE READING:https://www.newyorker.com/news/dispatch/how-do-you-shelter-in-place-when-you-dont-have-a-home

​Follow The New Yorker’s latest coverage of covid-19.View all stories

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FOSTER CITY, Calif.--(BUSINESS WIRE)-- Gilead Sciences, Inc. (NASDAQ: GILD) announced today that the U.S. Food and Drug Administration (FDA) has approved a supplemental New Drug Application (sNDA) for Epclusa® (sofosbuvir 400mg/velpatasvir 100mg; sofosbuvir 200mg/velpatasvir 50 mg) for the treatment of people with chronic hepatitis C infection (HCV) as young as 6 years of age or weighing at least 17 kg, regardless of HCV genotype or liver disease severity. The recommended dosage of Epclusa in children ages 6 years and older is based on weight and liver function. Epclusa is the first pan-genotypic, protease inhibitor-free regimen approved in the United States for adults and children.
In the United States, there are approximately 23,000-46,000 children living with HCV. Children born to mothers with HCV are a growing concern, increasing in prevalence by 60 percent from 2011 to 2014. Additionally, engagement in high‐risk practices, such as intravenous drug use, is an increasingly common route of HCV transmission in adolescents and young adults.
“While the treatment of HCV has been transformed in recent years, physicians caring for some children have still needed to take several factors into consideration, including genotype and liver disease severity, when selecting the appropriate treatment plan,” said Kathleen B Schwarz, M.D., Professor of Pediatrics, Johns Hopkins University School of Medicine. “The expanded approval of Epclusa can help eligible children living with HCV combat this life-threatening and debilitating disease.”
TO CONTINUE READING:  https://www.gilead.com/news-and-press/press-room/press-releases/2020/3/us-food-and-drug-administration-approves-epclusa-sofosbuvirvelpatasvir-for-children-ages-6-and-older-or-weighing-at-least-17-kg-with-chronic-hep

Daniel Raymond
Mar 15 


We have never had the luxury of being innocent to viruses nor epidemics. Our most codified histories trace the emergence of harm reduction in the United States to the grassroots mobilization against the wildfire ravages of the AIDS crisis among people who use drugs through community education and syringe exchange programs. More recently, mainstream narratives of harm reduction coalesce around collective action to stem the overdose epidemic through naloxone distribution and other user-centered strategies to maximize safety in the midst of stigma, criminalization, and precarity.
But harm reduction was never just about the drugs or the deaths or the diseases; we are more than the auxiliary or stepchild of public health. Our richest work embraces much deeper and more diverse genealogies. Harm reduction is heir to the multiple legacies of the communities and struggles we come from and move through, the hybrid wisdom that emerges from communal survival in the face of threats of being dispossessed, disenfranchised, displaced, disappeared.
As we confront COVID-19/SARS-CoV-2, let us remember the gifts of harm reduction:
TO CONTINUE READING:​https://medium.com/@danielraymond/harm-reduction-in-the-time-of-coronavirus-553e16c76623
 

by Aubrey Whelan and Jeremy Roebuck, Updated: February 25, 2020- 10:23 PM
The Philadelphia Inquirer

The country’s first supervised-injection site will open next week in South Philadelphia, the site’s operators said Tuesday within hours of a federal judge’s entering a final ruling that the proposed facility would not violate federal law.

The organizers behind Safehouse, the nonprofit formed to open the site, were expected to announce details of their plan at a news conference Wednesday.

They would not comment on the exact location of the site Tuesday evening, but sources familiar with the decision confirmed that the site would operate out of Constitution Health Plaza, 1930 S. Broad St., just steps from Passyunk Avenue. The site would have a separate entrance for its clients.

The organization plans to open a second site elsewhere in the city shortly after the South Philadelphia opening. The city has also issued a public-safety plan for the area outside a site, and Safehouse has been training volunteer escorts, like those that abortion providers have used for years to protect women.
The opening is the culmination of a two-year battle to open a place where people in addiction can use drugs under medical supervision, be revived if they overdose, and access treatment.

​TO CONTINUE READING: https://www.inquirer.com/news/philadelphia-supervised-injection-site-opening-federal-ruling-20200225.html

Bull-Otterson L, et al. J Infect Dis. 2020;doi.org/10.1093/infdis/jiaa017. HEALIO Infectious Disease News
February 20, 2020

Using data from more than 840,000 health care encounters, researchers estimated that around 90% of people who inject drugs missed opportunities for HIV or hepatitis C virus testing during a recent 8-year period — especially rural males seeking care for skin infections or endocarditis.
“We were interested in assessing HIV and hepatitis C infection testing rates for patients with substance use disorders, and in understanding opportunities for increasing testing rates at clinical visits,” Lara Bull-Otterson, PhD, MPH, an epidemiologist in the CDC’s National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention, told Healio. “Currently there is not a specific billing code to indicate that a person injects drugs. Such a code would be helpful to identify people who inject drugs (PWID) who might require HIV and hepatitis C testing and other important health care services, such as substance use treatment or overdose prevention interventions.”

​Bull-Otterson and colleagues used a nationwide health insurance database to assess the prevalence of testing for HIV and HCV infection among patients with claims filed between 2010 and 2017 who had at least one diagnosis, procedure or medication dispensed that was indicative of injection drug use. The researchers then estimated the percentage of PWID tested for HIV or HCV and assessed demographic and clinical factors associated with testing.
Overall, they found that approximately 90% of 844,242 PWID missed opportunities for testing — 71,938 (8.5%) were tested for HIV and 65,188 (7.7%) for HCV. According to the study, missed opportunities were independently associated with being male (OR for HIV = 0.5; 95% CI, 0.49-0.50; OR for HCV = 0.66; 95% CI, 0.65-0.72), having a rural residence (OR for HIV = 0.67; 95% CI, 0.65-0.69; OR for HCV = 0.75; 95% CI, 0.73-0.77) and receiving services for skin infections or endocarditis (adjusted OR [aOR] for HIV = 0.91; 95% CI, 0.87-0.95; aOR for HCV = 0.90; 95% CI, 0.86-0.95).
Bull-Otterson and colleagues used a nationwide health insurance database to assess the prevalence of testing for HIV and HCV infection among patients with claims filed between 2010 and 2017 who had at least one diagnosis, procedure or medication dispensed that was indicative of injection drug use. The researchers then estimated the percentage of PWID tested for HIV or HCV and assessed demographic and clinical factors associated with testing.

Overall, they found that approximately 90% of 844,242 PWID missed opportunities for testing — 71,938 (8.5%) were tested for HIV and 65,188 (7.7%) for HCV. According to the study, missed opportunities were independently associated with being male (OR for HIV = 0.5; 95% CI, 0.49-0.50; OR for HCV = 0.66; 95% CI, 0.65-0.72), having a rural residence (OR for HIV = 0.67; 95% CI, 0.65-0.69; OR for HCV = 0.75; 95% CI, 0.73-0.77) and receiving services for skin infections or endocarditis (adjusted OR [aOR] for HIV = 0.91; 95% CI, 0.87-0.95; aOR for HCV = 0.90; 95% CI, 0.86-0.95).

TO CONTINUE READING:https://www.healio.com/infectious-disease/hiv-aids/news/online/%7B949ff58c-451b-4485-9b33-699d70b397d4%7D/90-of-injection-drug-users-miss-opportunities-for-hiv-or-hcv-testing

​In rural Carter County, Tenn., health officials have embraced a strategy for stemming addiction: Teaching children as young as 6 how to administer Narcan, a nasal spray that can stop an opioid overdose from being fatal.

By Dan Levin- NY TIMES
Feb 23 2020

ELIZABETHTON, Tenn. — Shortly after his first-grade class let out for the day, Nash Kitchens sat with a dozen other young children at a library and played a murder mystery game that had a surprising plot twist.
The victim was a restaurant worker who had been found dead in a freezer. The killer, the children would discover, was heroin laced with fentanyl, an often fatal opioid.
Nash, who at 7 years old has a relative who has struggled with addiction, was wide-eyed as Jilian Reece, a drug prevention educator, talked about an ongoing opioid epidemic in their small rural community. She then demonstrated how to administer Narcan, an overdose reversal nasal spray.
“It’s just like a little squirt gun,” she told the group of children, before passing around the small plastic device for them to hold and squeeze. At the end of the session, each child received a blue zippered bag containing two doses of Narcan to take home.

Like scores of communities across America, Carter County, Tenn., which includes Elizabethton, has been struck hard by an opioid crisis that has ravaged families and reshaped how a generation of young people are being raised. Nationally, few cities have been spared as more than 400,000 Americans have died from opioid overdoses.
In Carter County, where 56,000 people live in a cluster of small cities and rural towns on the North Carolina border, nearly 60 people have died from opioid overdoses since 2014. That year, 8.1 million painkiller prescriptions were written in Tennessee, more than the state’s population of about 6.5 million.



Desperate to save lives, county health officials have embraced a practical — if radical — strategy for stemming the tide of addiction: Teaching children as young as 6 how to reverse an overdose.
In the past three years, the county’s drug prevention coalition has given Narcan training to an estimated 600 young children and teenagers in after-school programs, babysitting classes and vaping cessation courses. Some of the young people have in turn trained their peers and taken a leading role in distributing Narcan at community events, like a back-to-school bash last fall where one child gave out 70 doses.

TO CONTINUE READING: https://www.nytimes.com/2020/02/23/us/opioids-tennessee-narcan-training.html?nl=todaysheadlines&emc=edit_th_200224&cam

Feb 4, 2020, 

Nina ShapiroContributor 
Healthcare
Dispelling health myths, fads, exaggerations and misconceptions.

Baby boomers have gotten a lot of flack lately. Those born between 1945-1965, during the post-World War II years, many of who are entering retirement age, have been the subject of many a snarky millennial-driven meme. Not sure what a meme is? OK, Boomer, you need to Google that. You’re not sure what Google is? OK, Boomer. You still don’t get what “OK, Boomer” means? OK...
But all memes aside, and all acute devastating viruses aside, including influenza virus and the novel coronavirus, a more prevalent virus, which is hardly new, is wreaking havoc on baby boomers.

While many of the newer viruses can infect and affect anybody at any age, certain viruses, especially those prevented by widespread vaccination programs, have become infections of the past. Thanks to Dr. Jonah Salk, polio, a viral infection which decimated and paralyzed swaths of pre-boomer populations, is something most boomers never saw. But in the 1960’s-1980’s, the years before utilization of universal precautions and infection control in the healthcare setting, transmission of the Hepatitis C virus, via contaminated medical equipment, or by contact with contaminated blood products, led to easy transmission of this virus from either person to person or via contaminated needles or medical instruments. The virus can also be transmitted via sexual contact, with much higher incidence of transmission risk prior to more commonly used protection against more widely recognized sexually transmitted infections. While even back in those distant decades it would seem rare to have contact with contaminated medical supplies, the numbers declare otherwise, likely, in part, due to lesser use of condoms during sexual contact as well as substandard cleaning practices of medical instruments. Approximately one in thirty individuals born from 1945-1965 screen positive for Hepatitis C. Another way of looking at it shows that over 75% of those with Hepatatis C are baby boomers. Routine screening of blood products used for transfusion to eliminate transmission of Hepatitis C began in 1992.

TO CONTINUE READING: https://www.forbes.com/sites/ninashapiro/2020/02/04/baby-boomers-have-high-incidence-of-hepatitis-c-virus-what-does-this-mean-boomer/#37c3c82c103f

​Jan. 23, 2020
The National Academies of Science. Engineering .Medicine

WASHINGTON — The opioid epidemic in the U.S. is driving a simultaneous epidemic of infectious diseases — including HIV, hepatitis C virus (HCV) and bacterial infections, and sexually transmitted infections — but workforce shortages, stigma, and financial and policy barriers are preventing the integration of opioid use disorder (OUD) and infectious disease services, says a new report from the National Academies of Sciences, Engineering, and Medicine. The report recommends state and federal policy actions, including removing insurance requirements on prescribing medications for OUD (i.e., buprenorphine), expanding access to medications in criminal justice settings, and lifting state bans on syringe service programs.

The rise of infectious diseases related to OUD is attributed to sharing needles, having unprotected sex, and lacking access to medical care, says Opportunities to Improve Opioid Use Disorder and Infectious Disease Services: Integrating Responses to a Dual Epidemic. Over the past few years, four states hardest hit by the opioid epidemic — Tennessee, Kentucky, Ohio, and West Virginia — have seen a 364 percent increase in acute HCV infections. In rural areas in particular, there is a shortage of providers — including physicians, social workers, therapists, and counselors — available to care for patients in an integrated way.

Methadone clinics, primary care clinics, and jails and prisons see thousands of patients with concurrent OUD and infectious diseases annually, and should be leveraged as integrated care sites, the report says. However, some organizations are unable to provide integrated services because of restrictions on the types of services they can provide. For example, some state Medicaid laws do not allow billing for medical care and behavioral health services on the same day. Other states ban syringe service programs, despite evidence that these programs can link patients to more intensive treatment for OUD and infectious disease as well as prevent new cases of infectious disease.

“Substance and opioid use disorder treatment is already segregated from traditional medical care. Treating OUD and infectious diseases as separate epidemics only reinforces stigma,” said Carlos del Rio, professor of medicine at Emory University School of Medicine and professor of global health at the Rollins School of Public Health of Emory University, and chair of the committee that wrote the report. “The better we integrate services, the sooner we can connect people to diagnosis, treatment, and prevention and achieve successful health outcomes.”

​TO CONTINUE READING:http://www8.nationalacademies.org/onpinews/newsitem.aspx?RecordID=25626