Cascade of care among hepatitis B patients in Maastricht, the Netherlands, 1996 to 2018

Abstract

Background & aims: There are approximately 49,000 people (0.34%) in the Netherlands with a chronic hepatitis B virus (HBV) infection. It is unclear how many are linked to care and under follow-up in hepatitis outpatient clinics. This study determined the cascade of care and identified predictors for not being linked to care and loss to follow-up in Maastricht, the Netherlands.

Methods: All hepatitis B surface antigen (HBsAg)-positive patients between December 1, 1996 and September 30, 2018 were retrospectively identified.

Results: In total, 644 HBsAg-positive patients were identified; of whom 75 had acute HBV infection, 471 chronic HBV infection and 98 unknown. Out of 569 individuals with a chronic/unknown HBV status, 134/569 (23.6%) were not linked to care and 58.7% (195/332 after excluding those who died or achieved HBsAg-seroclearance) were loss to follow-up (LTFU). A predictor for not being linked to care was Caucasian ethnicity (odds ratio (OR) = 2.76 (95% Confidence Interval (CI) = 1.21-6.29); p = .015). Predictors for LTFU were older age (OR = 0.97 (CI = 0.94-0.99); p = .008), HBV DNA >20,000 IU/mL (OR = 0.44 (CI = 0.21 - 0.93); p = .033) and Asian ethnicity (OR = 0.46, (CI = 0.21-1.00); p = .050). Rates of not being linked to care and LTFU decreased over time from 12.7% in 1996 to 4.4% in 2018 and from 79.2% in 1996 to 37.2% in 2018, respectively.

Conclusions: A considerable amount of HBsAg-positive individuals were not linked to care or LTFU. This study indicates that ethnicity plays a role in linkage to care and follow-up. Further research is needed to elaborate on those results.

Keywords: Cascade of care; Ethnicity; Hepatitis B; Linkage to care; Loss to follow-up; The Netherlands.

Fig. 1

Cascade of care for HBsAg-positive patients within the region of Maastricht, The Netherlands (n=644) Abbreviations: HBsAg: Hepatitis B surface Antigen; LTFU: Loss to follow-up. Definitions: Chronic HBV infection: more than 6 months of HBsAg positivity; Acute HBV infection: patients with the appropriate symptoms/signs and laboratory confirmation: 1) a positive test for HBsAg and hepatitis B core antibodies (anti-HBc) IgM, 2) detection of HBsAg and previous negative markers or, 3) detection of HBV DNA and previous negative HBV markers; Unknown cases: those without laboratory confirmation and a HBsAg-positivity < 6 months. Linked to care: HBsAg-positive patients with an infectious disease specialist or hepatologist evaluation; Eligible for treatment: according to the EASL guidelines; loss to follow-up: no specialist evaluation >1 year with previous evaluation.

Fig. 2

Cascade of care in chronic hepatitis B patients presented as columns (n=471) Abbreviations: HBV: Hepatitis B virus. Definitions: Chronic HBV infection: more than 6 months of HBsAg positivity; Linked to care: HBsAg-positive patients with an infectious disease specialist or hepatologist evaluation; Eligible for treatment: according to the EASL guidelines; HBV suppression: HBV DNA of <60–80 IU/ml.

Fig. 3

Proportion of individuals with chronic hepatitis B virus infection not linked to care or loss to follow-up over period 1996–2018 (n=471). Abbreviations: HBV, Hepatitis B virus. Definitions: not linked to care: HBsAg-positive patients without an infectious disease specialist or hepatologist evaluation; loss to follow-up, no specialist evaluation >1 year with previous evaluation.