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Future of hepatitis c care in the netherlands

of care for
Future of
hepatitis C care in
Think Tank hepatitis C care in the Netherlands
under guidance of The Argumentation Factory
This report was created by: The Argumentation Factory
ContentDr Maaike de Vries Drs Silvie Zonderland DesignWillem van den Goorbergh Sponsored byAbbVie How did this report Over the next few months, new hepatitis C drugs will come onto the market. They will increase the chance What does the care process for patients with of curing the disease to more than 95 percent. The hepatitis C look like at the moment? Which facts arrival of new drugs requires a critical reassessment about hepatitis C are relevant when considering an of hepatitis C care in the Netherlands. What should action plan? Which developments are there? The the ideal care for hepatitis C look like in 2015? And results of this thinking are on the Care Map, the Facts how are we going to get there? Map, and the Trends and Factors Map. Under guidance of The Argumentation Factory, a Think Tank of experts has pondered this question. The members of the Think Tank reflected on the issue What should care for hepatitis C look like in the near from their role as expert, keeping their own interests future? The Vision Map shows the Think Tank's vision as separate as possible. They spoke in a personal of hepatitis C care in the Netherlands. capacity rather than on behalf of their organization. Biopharmacist AbbVie initiated and sponsored the 3. Concretization Based on the first two thinking steps, the Think Tank This report is the result of four thinking sessions formulated specific guidelines in order to realize the and two interviews with a total of twelve experts in vision. What needs to happen specifically in order to the field of hepatitis C. The Think Tank convened realize the vision? Who, in the Think Tank's opinion, during the summer and autumn of 2014. is best able to implement this? The answers to these The Think Tank went through three thinking steps. questions can be found in the Action Map. First of all, they drew up an analysis of what hepatitis C care looks like at the moment. This analysis gave This book of maps will serve as a basis for them a clear starting point from which the Think healthcare providers, policy makers, and others Tank looked at the future. Secondly, the Think Tank involved with hepatitis C. The results of the Think formulated a vision. The Think Tank then developed Tank's work can be used as a starting point for a this vision in the third and final thinking step: ‘national action plan' in order to jointly improve care concretization. Concretization is the first step towards for hepatitis C. the realization and implementation of the vision. The result of these three thinking steps is contained in this Dr Maaike de Vries report and presented as follows in the form of maps: Drs Shaun Lednor Drs Silvie Zonderland Table of contents How did this report come about? Notes accompanying the maps Care Map for Hepatitis C Facts Map for Hepatitis C Trends and Factors Map for Hepatitis C Vision Map for Hepatitis C Action Map for Hepatitis C Information lists Sources and abbreviations accompanying the maps Map 1. Current care This map shows what current care for patients with Based on the previous analysis, the Think Tank hepatitis C looks like. It forms the starting point for reached a vision. The vision shows what the future of the Think Tank's work. What does the world look like hepatitis C care in the Netherlands should look like. now and what would we like to change? It is a broad vision which is elaborated upon in the Map 2. Facts The Facts Map is a graphic display of key hepatitis C figures. The Action Map indicates what should happen for the vision to be realized. Together the actions form Map 3. Trends and Factors a starting point for a national viral hepatitis steering The Trends and Factors Map shows the committee whose job it would be to elaborate on the developments and factors that the Think Tank considers significant when reflecting upon hepatitis C care. They concern the structure and cost of care as well as the whole disease and care process; from infection to treatment. What is hepatitis C?Hepatitis C is caused by the hepatitis C virus remove the virus from the body of 20 to 25 percent (HCV). This virus can cause infections in the liver. of the infected individuals. These infections can lead to the formation of A patient with chronic hepatitis C (an HCV scarring in the liver. This, in turn, can lead to a infection which has existed for more than six reduction of liver function. Scarring can ultimately months) does not necessarily feel ill; it can take up lead to liver cirrhosis and liver cancer with possibly to forty years before the patient is troubled by fatal consequences. Hepatitis C is a major cause hepatitis C. The current treatment methods for for liver transplantation. There are no exact hepatitis C are long-lasting and tough. The figures on the prevalence of hepatitis C. There medicines contain the substance Peginterferon are estimated to be 15,000-60,000 Dutch which has to be administered subcutaneously, and hepatitis C sufferers. Migrants form the largest there are a lot of side effects. Many patients have difficulty completing the treatment. The new treatment methods do not last as How do you get hepatitis C? long, the medicines are easier to take, and there HCV can be transmitted via blood. The incubation are fewer side effects. Moreover, the chance period for acute hepatitis C is approximately seven of recovery increases to more than 95 percent. weeks to three months. In the case of an acute These new medicines will become available in the HCV infection, the immune system itself is able to Netherlands from the end of 2014.
Care Map for hepatitis C
The patient develops symptoms
The patient presents (vague) health problems to their general practitioner, for example fatigue and abdominal pain.
The general practitioner has the patient tested for HCV.
The general practitioner reports acute hepatitis C to the RIVM's virology laboratory.
The patient does not develop any (clear) symptoms
The patient is tested for HCV by the Public Health Service (GGD), blood bank, or Custodial Institutions Agency (DJI).
The patient undergoes blood tests for HCV in the hospital or at the blood bank.
The patient presents (vague) health problems to their general practitioner, and liver tests show HCV infection.
Risk groups are actively approached for screening
Some GGDs and addiction clinics run screening projects for risk groups.
The patient has acute hepatitis C
What does
The general practitioner immediately sends the patient to hospital.
hepatitis C care
Treatment does not always start immediately; sometimes the disease is allowed to follow its natural course for three to six months.
currently look like
The patient has chronic hepatitis C
The patient is examined by a gastroenterologist or an infectious disease specialist in a hepatitis treatment centre.
The physician assesses whether treatment is required.
The physician adapts the treatment to the genotype of the virus, the symptoms, and other individual factors.
Drug users sometimes receive support from addiction care specialists during treatment.
The patient receives treatment with injections and/or pills.
The treatment lasts six months to a year.
The treatment is paid for via the Healthcare Insurance Act.
The physician monitors the adherence to and effects of the therapy.
In addition to chronic hepatitis C, the patient has cirrhosis of the liver
Where there is serious cirrhosis, the patient needs to be given a liver transplant.
Six months after treatment, the patient is tested for the presence of the virus in the blood.
If the virus is no longer present in the blood, the patient is no longer monitored.
If the virus is still present in the blood, the patient continues to be monitored.
If the patient has cirrhosis of the liver, they continue to be monitored.
If the patient still runs the risk of HCV infection, they are monitored for reinfection.
Care Map for hepatitis C
The patient develops symptoms
The patient presents (vague) health problems to their general practitioner, for example fatigue and abdominal pain.
The general practitioner has the patient tested for HCV.
The general practitioner reports acute hepatitis C to the RIVM's virology laboratory.
The patient does not develop any (clear) symptoms
The patient is tested for HCV by the Public Health Service (GGD), blood bank, or Custodial Institutions Agency (DJI).
The patient undergoes blood tests for HCV in the hospital or at the blood bank.
The patient presents (vague) health problems to their general practitioner, and liver tests show HCV infection.
Risk groups are actively approached for screening
Some GGDs and addiction clinics run screening projects for risk groups.
The patient has acute hepatitis C
What does
The general practitioner immediately sends the patient to hospital.
hepatitis C care
Treatment does not always start immediately; sometimes the disease is allowed to follow its natural course for three to six months.
currently look like
The patient has chronic hepatitis C
The patient is examined by a gastroenterologist or an infectious disease specialist in a hepatitis treatment centre.
The physician assesses whether treatment is required.
The physician adapts the treatment to the genotype of the virus, the symptoms, and other individual factors.
Drug users sometimes receive support from addiction care specialists during treatment.
The patient receives treatment with injections and/or pills.
The treatment lasts six months to a year.
The treatment is paid for via the Healthcare Insurance Act.
The physician monitors the adherence to and effects of the therapy.
In addition to chronic hepatitis C, the patient has cirrhosis of the liver
Where there is serious cirrhosis, the patient needs to be given a liver transplant.
Six months after treatment, the patient is tested for the presence of the virus in the blood.
If the virus is no longer present in the blood, the patient is no longer monitored.
If the virus is still present in the blood, the patient continues to be monitored.
If the patient has cirrhosis of the liver, they continue to be monitored.
If the patient still runs the risk of HCV infection, they are monitored for reinfection.
Facts Map for hepatitis C
Worldwide, around 2 percent of the population is infected; in the Netherlands around 0.2 percent.
In the Netherlands, it is estimated that around 500 people a year die from hepatitis C and B.
Dutch population 0.2 Source: 1a
Malignant liver tumour Concentrations of HCV are found around the Mediterranean and in Asia.
Chronic liver disorder Other infectious diseases Statline: Causes of Death, Hepatitis, Primary liver, malignancy*0,26, cirrhosis*0,35
Source: 5
Percentage of the population infected with the hepatitis C virus: Source: 2
There are around a thousand treatments per year.
Dutch infections are largely contracted abroad.
Treatments with both Peginterferon and Ribavirin relevant facts in
and NS3 protease inhibitors Resulting from intravenous drug use thinking about the
future of care for
infected
HIV positive men who have sex with other men hepatitis C in the
Treatments with Peginterferon and Ribavirin inhabitants of
Resulting from blood transfusion before 1992 2007 2008 2009 2010 Source: 6
Migrants from risk countries Source: 3
The number of reports of hepatitis C are in decline.
The cost of hepatitis C medicines has increased by more than 50 percent over recent years.
Total cost in millions of euros Source: 7
Source: 4
Facts Map for hepatitis C
Worldwide, around 2 percent of the population is infected; in the Netherlands around 0.2 percent.
In the Netherlands, it is estimated that around 500 people a year die from hepatitis C and B.
Dutch population 0.2 Source: 1a
Malignant liver tumour Concentrations of HCV are found around the Mediterranean and in Asia.
Chronic liver disorder Other infectious diseases Statline: Causes of Death, Hepatitis, Primary liver, malignancy*0,26, cirrhosis*0,35
Source: 5
Percentage of the population infected with the hepatitis C virus: Source: 2
There are around a thousand treatments per year.
Dutch infections are largely contracted abroad.
Treatments with both Peginterferon and Ribavirin relevant facts in
and NS3 protease inhibitors Resulting from intravenous drug use thinking about the
future of care for
infected
HIV positive men who have sex with other men hepatitis C in the
Treatments with Peginterferon and Ribavirin inhabitants of
Resulting from blood transfusion before 1992 2007 2008 2009 2010 Source: 6
Migrants from risk countries Source: 3
The number of reports of hepatitis C are in decline.
The cost of hepatitis C medicines has increased by more than 50 percent over recent years.
Total cost in millions of euros Source: 7
Source: 4
Trends and Factors Map for hepatitis C
The organization of care and support has improved but is not yet optimal
Since 2012, the Netherlands has around 48 specialist treatment centres for HCV.
Hospitals do not have a standard treatment plan or priorities for treatment per target group.
The course of the HCV disease depends on various factors
Patients who have dropped out of or refused treatment have no access to programmes to get them to start (again).
Healthcare providers and policy makers place more focus on curing HCV than on quality of life.
Age, sex, lifestyle, such as alcohol use or being overweight, determine the course of the disease.
Many healthcare providers do not know how HCV support or treatment is funded.
Other diseases, such as HIV, determine the course of the disease.
The Dutch approach toward HCV can be improved by learning from abroad
HCV is a disease with a low mortality rate but potentially serious eff ects
In the Netherlands, the introduction of new HCV drugs takes longer than in other European countries.
Most patients with HCV die with the disease, but not as a result of it.
At a European level, there is an exchange of knowledge but no joint policy for HCV.
Despite effective medication, the number of fatalities from HCV and HBV has increased slightly since 1996.
Unlike Scotland and France, for example, the Netherlands has no national hepatitis plan.
Since 1996, the number of fatalities from the direct or indirect effects of HCV or HBV has increased from 450 to 500.
Since 1996, the number of fatalities from the direct or indirect effects of HIV has decreased from 327 to 44.
HCV does not always need to be treated
HCV occurs relatively infrequently in the Netherlands
Whether or not treatment is provided depends on the medical prognoses and the patient's risk behaviour.
Exact prevalence rates are lacking; it is estimated that 0.22 percent of Dutch citizens are infected with HCV.
Some patients are physically, financially, and/or socially unprepared to complete the treatment successfully.
The use of intravenous drugs hardly ever occurs in the Netherlands.
A lack of a proper consultation structure between healthcare providers means patients are not always referred to a The transmission of HCV by blood transfusion has decreased due to improved hygiene.
specialist.
Addiction care specialists pay little attention to HCV in treatment programmes and make few arrangements with hospitals.
relevant trends and
Prison inmates with HCV are only treated if it is medically necessary.
Migrants, drug users, and men who have sex with other men are risk groups for HCV
factors in thinking
Half of current HCV infections occurred in non-western countries.
A quarter of current infections occurred through intravenous drug use.
about the future of care
Treatment of HCV is not optimal
At the moment, acute hepatitis C mainly occurs among men who have unprotected sex with other men.
for hepatitis C in the
As new therapies are expected, the Netherlands has currently called a ‘treatment stop'.
Some people who belong to a risk group are unware of this.
HCV infections are more common in lower socio-economic classes.
Until now, treatments for HCV can be accompanied by Peginterferon.
Treatments last six months to a year and are associated with side effects such as psychological symptoms.
The chances of recovery are around 50-80 percent and lower if patients also have HIV.
Around 20 percent of patients stop treatment prematurely because of the side effects.
In the case of serious cirrhosis of the liver, a liver transplant is the only course of treatment.
The minister has named three groups whose treatment is to be reimbursed.
HCV is given little attention by healthcare providers and is poorly recognized
The symptoms that belong to HCV, like fatigue, could also indicate other disorders.
General practitioners have insufficient knowledge about the risk groups, nor do they actively look for HCV.
New medicines make HCV more treatable
Most healthcare providers do not automatically test for HCV infection in cases of impaired liver function.
New medication has increased the chances of cure from HCV to 96 percent.
Healthcare providers must report acute HCV to the RIVM; the number of reports has decreased between 2008 and 2013.
The new treatments last 12-24 weeks and have few side effects.
Fewer people are getting tested because they have to pay for the tests themselves.
More than 80 percent of HCV infections run their course without symptoms and go unnoticed.
There is no systematic screening for HCV infections in the Netherlands
The current methods of treatment are reimbursed; new treatments as of 1 November 2014
Despite great efforts, the detection of HCV infections through screening projects is often low.
Health insurance companies pay the cost of current HCV treatments.
Where there is a positive HCV test, the patient's social environment is not tested as a standard procedure.
Health insurance companies will reimburse the new treatments for patients in an advanced stage.
Screening can have negative side effects, including psychological ones, such as fear, anxiety, and stigmatization.
The cost of current treatments comes to 25,000-60,000 euro per treatment per patient.
The current cost of the new treatments comes to 96,000 euro per treatment per patient.
The Ministry of Security and Justice pays the cost of treating detained patients.
Not everyone who tested positive for HCV in the past is still being monitored
Addiction care has a clear picture of current drug users, but not of former users.
Patients with HCV infection are not always monitored after diagnosis, nor are they placed on a national register.
Trends and Factors Map for hepatitis C
The organization of care and support has improved but is not yet optimal
Since 2012, the Netherlands has around 48 specialist treatment centres for HCV.
Hospitals do not have a standard treatment plan or priorities for treatment per target group.
The course of the HCV disease depends on various factors
Patients who have dropped out of or refused treatment have no access to programmes to get them to start (again).
Healthcare providers and policy makers place more focus on curing HCV than on quality of life.
Age, sex, lifestyle, such as alcohol use or being overweight, determine the course of the disease.
Many healthcare providers do not know how HCV support or treatment is funded.
Other diseases, such as HIV, determine the course of the disease.
The Dutch approach toward HCV can be improved by learning from abroad
HCV is a disease with a low mortality rate but potentially serious eff ects
In the Netherlands, the introduction of new HCV drugs takes longer than in other European countries.
Most patients with HCV die with the disease, but not as a result of it.
At a European level, there is an exchange of knowledge but no joint policy for HCV.
Despite effective medication, the number of fatalities from HCV and HBV has increased slightly since 1996.
Unlike Scotland and France, for example, the Netherlands has no national hepatitis plan.
Since 1996, the number of fatalities from the direct or indirect effects of HCV or HBV has increased from 450 to 500.
Since 1996, the number of fatalities from the direct or indirect effects of HIV has decreased from 327 to 44.
HCV does not always need to be treated
HCV occurs relatively infrequently in the Netherlands
Whether or not treatment is provided depends on the medical prognoses and the patient's risk behaviour.
Exact prevalence rates are lacking; it is estimated that 0.22 percent of Dutch citizens are infected with HCV.
Some patients are physically, financially, and/or socially unprepared to complete the treatment successfully.
The use of intravenous drugs hardly ever occurs in the Netherlands.
A lack of a proper consultation structure between healthcare providers means patients are not always referred to a The transmission of HCV by blood transfusion has decreased due to improved hygiene.
specialist.
Addiction care specialists pay little attention to HCV in treatment programmes and make few arrangements with hospitals.
relevant trends and
Prison inmates with HCV are only treated if it is medically necessary.
Migrants, drug users, and men who have sex with other men are risk groups for HCV
factors in thinking
Half of current HCV infections occurred in non-western countries.
A quarter of current infections occurred through intravenous drug use.
about the future of care
Treatment of HCV is not optimal
At the moment, acute hepatitis C mainly occurs among men who have unprotected sex with other men.
for hepatitis C in the
As new therapies are expected, the Netherlands has currently called a ‘treatment stop'.
Some people who belong to a risk group are unware of this.
HCV infections are more common in lower socio-economic classes.
Until now, treatments for HCV can be accompanied by Peginterferon.
Treatments last six months to a year and are associated with side effects such as psychological symptoms.
The chances of recovery are around 50-80 percent and lower if patients also have HIV.
Around 20 percent of patients stop treatment prematurely because of the side effects.
In the case of serious cirrhosis of the liver, a liver transplant is the only course of treatment.
The minister has named three groups whose treatment is to be reimbursed.
HCV is given little attention by healthcare providers and is poorly recognized
The symptoms that belong to HCV, like fatigue, could also indicate other disorders.
General practitioners have insufficient knowledge about the risk groups, nor do they actively look for HCV.
New medicines make HCV more treatable
Most healthcare providers do not automatically test for HCV infection in cases of impaired liver function.
New medication has increased the chances of cure from HCV to 96 percent.
Healthcare providers must report acute HCV to the RIVM; the number of reports has decreased between 2008 and 2013.
The new treatments last 12-24 weeks and have few side effects.
Fewer people are getting tested because they have to pay for the tests themselves.
More than 80 percent of HCV infections run their course without symptoms and go unnoticed.
There is no systematic screening for HCV infections in the Netherlands
The current methods of treatment are reimbursed; new treatments as of 1 November 2014
Despite great efforts, the detection of HCV infections through screening projects is often low.
Health insurance companies pay the cost of current HCV treatments.
Where there is a positive HCV test, the patient's social environment is not tested as a standard procedure.
Health insurance companies will reimburse the new treatments for patients in an advanced stage.
Screening can have negative side effects, including psychological ones, such as fear, anxiety, and stigmatization.
The cost of current treatments comes to 25,000-60,000 euro per treatment per patient.
The current cost of the new treatments comes to 96,000 euro per treatment per patient.
The Ministry of Security and Justice pays the cost of treating detained patients.
Not everyone who tested positive for HCV in the past is still being monitored
Addiction care has a clear picture of current drug users, but not of former users.
Patients with HCV infection are not always monitored after diagnosis, nor are they placed on a national register.
Vision Map for hepatitis C
In the Netherlands, nobody dies of HCV any more
Patients with HCV are treated before they get cirrhosis of the liver.
An HCV infection is less likely to lead to liver damage.
Treatment is carefully considered
HCV care is coordinated and focused
Patients with cirrhosis of the liver and severe fibrosis are given priority for treatment of HCV.
Healthcare providers make regional arrangements about referrals, treatment, and support.
The greater the chances patients have of passing the virus on, the sooner they are treated.
Treatment for HCV only takes place in centres that meet quality criteria of the relevant medical specialists.
The greater the chances patients have of completing the therapy, the sooner they are treated.
Healthcare providers take account of the aftercare of HCV patients, such as reintegration.
Prisoners with HCV are treated, especially if they will still be imprisoned after the treatment has ended.
Knowledge and data about HCV are stored and shared nationally
After diagnosis, all patients are given a care plan and continue to be monitored, even if they are not undergoing treatment
Healthcare providers register patients in a national data bank.
Healthcare providers draw up a care plan in consultation with patients.
Laboratories add data about existing HCV infections to the national register.
Healthcare providers and patients monitor progress and adapt the care plan if necessary.
Policy makers use the national register for policy purposes.
Healthcare providers make the care plan understandable for patients, using plain language and clear agreements.
What is our
Prisoners diagnosed with HCV are given a care plan that continues after their release.
vision on the
detection and care for
Healthcare providers are familiar with the latest developments
More people, especially those in risk groups, are informed about hepatitis C
hepatitis C in the
Healthcare providers know how the new drugs work and how effective they are among various patient groups.
The Dutch population knows what hepatitis C is and how it can be prevented and treated. Risk groups know why it is wise to get screened for HCV.
People belonging to risk groups are informed by GGDs, RIVM, DJI, and addiction care.
HCV care remains aff ordable
The cost of treating HCV with new drugs needs to come down in the next few years.
Healthcare providers are alert to potential HCV infections
The care and detection of HCV are cost effective.
Healthcare providers are capable of identifying HCV infections.
Like general practitioner care, the HCV test does not fall within personal liability.
Healthcare providers know that an HCV infection is an easily treatable condition.
Funding does not stand in the way of treating prisoners with HCV.
HCV is routinely and nationally detected
High-risk groups are routinely screened and informed about what it is, how it happens and why this is so.
Where possible, screening for HCV is combined with screening for other (infectious) diseases.
Anyone who has ever been diagnosed with HCV but has gotten out of sight is localised and given a care plan.
Every adult is tested for HCV, HBV, and HIV at least once in their lifetime.
Vision Map for hepatitis C
In the Netherlands, nobody dies of HCV any more
Patients with HCV are treated before they get cirrhosis of the liver.
An HCV infection is less likely to lead to liver damage.
Treatment is carefully considered
HCV care is coordinated and focused
Patients with cirrhosis of the liver and severe fibrosis are given priority for treatment of HCV.
Healthcare providers make regional arrangements about referrals, treatment, and support.
The greater the chances patients have of passing the virus on, the sooner they are treated.
Treatment for HCV only takes place in centres that meet quality criteria of the relevant medical specialists.
The greater the chances patients have of completing the therapy, the sooner they are treated.
Healthcare providers take account of the aftercare of HCV patients, such as reintegration.
Prisoners with HCV are treated, especially if they will still be imprisoned after the treatment has ended.
Knowledge and data about HCV are stored and shared nationally
After diagnosis, all patients are given a care plan and continue to be monitored, even if they are not undergoing treatment
Healthcare providers register patients in a national data bank.
Healthcare providers draw up a care plan in consultation with patients.
Laboratories add data about existing HCV infections to the national register.
Healthcare providers and patients monitor progress and adapt the care plan if necessary.
Policy makers use the national register for policy purposes.
Healthcare providers make the care plan understandable for patients, using plain language and clear agreements.
What is our
Prisoners diagnosed with HCV are given a care plan that continues after their release.
vision on the
detection and care for
Healthcare providers are familiar with the latest developments
More people, especially those in risk groups, are informed about hepatitis C
hepatitis C in the
Healthcare providers know how the new drugs work and how effective they are among various patient groups.
The Dutch population knows what hepatitis C is and how it can be prevented and treated. Risk groups know why it is wise to get screened for HCV.
People belonging to risk groups are informed by GGDs, RIVM, DJI, and addiction care.
HCV care remains aff ordable
The cost of treating HCV with new drugs needs to come down in the next few years.
Healthcare providers are alert to potential HCV infections
The care and detection of HCV are cost effective.
Healthcare providers are capable of identifying HCV infections.
Like general practitioner care, the HCV test does not fall within personal liability.
Healthcare providers know that an HCV infection is an easily treatable condition.
Funding does not stand in the way of treating prisoners with HCV.
HCV is routinely and nationally detected
High-risk groups are routinely screened and informed about what it is, how it happens and why this is so.
Where possible, screening for HCV is combined with screening for other (infectious) diseases.
Anyone who has ever been diagnosed with HCV but has gotten out of sight is localised and given a care plan.
Every adult is tested for HCV, HBV, and HIV at least once in their lifetime.
Action Map for hepatitis C
HCV care is coordinated and focused VISION
Stakeholders such as healthcare providers, RIVM, and the government join together in a viral hepatitis steering committee.
The steering committee forms a national strategy using the action points formulated here as a starting point.
The steering committee ensures the implementation of the strategy and the action plan.
The steering committee formulates and monitors performance agreements based on the action points.
The steering committee keeps the action plan, including funding, on the agendas of authorities.
The steering committee is committed to ensuring that HCV screening is quickly covered by the Population Screening Act.
Pharmaceutical companies make money available through the government for detecting hepatitis C.
VISION Treatment is carefully considered
Healthcare providers determine regionally how care for various risk groups is to proceed.
Relevant medical specialists adapt the guidelines for HCV.
After diagnosis, all patients are given a care plan and continue to be monitored, even if they are not
Who needs
More people, especially those in risk groups, are informed about hepatitis C VISION
to do what in order
The Ministries of Justice, VWS, and health insurance companies make agreements about the treatment of prisoners who are released.
to realize the
The Ministries of Justice, VWS, and health insurance companies make agreements about the treatment Parties in public healthcare increase awareness among risk groups.
vision for
of migrants.
Parties in public healthcare increase awareness among the Dutch population.
Public healthcare uses effective awareness-raising practices from abroad.
hepatitis C?
The steering committee investigates the most effective awareness-raising campaigns.
VISION The cost of HCV care continues to be aff ordable for the Netherlands and patients
Healthcare providers are attentive to potential HCV infections VISION
The steering committee carries out a study into the most cost-effective method of care and detection.
The taskforce ensures combined HCV, HBV, and HIV training of healthcare providers.
The Ministry of VWS arranges for the HCV test to be outside personal liability.
The Ministry of Justice funds treatment of prisoners who meet treatment criteria.
The Ministry of VWS negotiates with pharmaceutical companies on the cost of new medicines.
HCV is routinely and nationally detected VISION
The GGD is in charge of finding patients who are out of sight.
HCV infections among migrants are detected using a screening programme.
Healthcare providers encourage risk groups to get screened for HCV, HBV, and HIV.
Healthcare providers use new technologies, for instance an app, to identify.
Prison physicians are encouraged to screen for HCV, HBV, and HIV and to set up a care plan.
The steering committee investigates how support for screenings among risk groups can be increased.
Healthcare providers register HCV infections in a national database.
Action Map for hepatitis C
HCV care is coordinated and focused VISION
Stakeholders such as healthcare providers, RIVM, and the government join together in a viral hepatitis steering committee.
The steering committee forms a national strategy using the action points formulated here as a starting point.
The steering committee ensures the implementation of the strategy and the action plan.
The steering committee formulates and monitors performance agreements based on the action points.
The steering committee keeps the action plan, including funding, on the agendas of authorities.
The steering committee is committed to ensuring that HCV screening is quickly covered by the Population Screening Act.
Pharmaceutical companies make money available through the government for detecting hepatitis C.
VISION Treatment is carefully considered
Healthcare providers determine regionally how care for various risk groups is to proceed.
Relevant medical specialists adapt the guidelines for HCV.
After diagnosis, all patients are given a care plan and continue to be monitored, even if they are not
Who needs
More people, especially those in risk groups, are informed about hepatitis C VISION
to do what in order
The Ministries of Justice, VWS, and health insurance companies make agreements about the treatment of prisoners who are released.
to realize the
The Ministries of Justice, VWS, and health insurance companies make agreements about the treatment Parties in public healthcare increase awareness among risk groups.
vision for
of migrants.
Parties in public healthcare increase awareness among the Dutch population.
Public healthcare uses effective awareness-raising practices from abroad.
hepatitis C?
The steering committee investigates the most effective awareness-raising campaigns.
VISION The cost of HCV care continues to be aff ordable for the Netherlands and patients
Healthcare providers are attentive to potential HCV infections VISION
The steering committee carries out a study into the most cost-effective method of care and detection.
The taskforce ensures combined HCV, HBV, and HIV training of healthcare providers.
The Ministry of VWS arranges for the HCV test to be outside personal liability.
The Ministry of Justice funds treatment of prisoners who meet treatment criteria.
The Ministry of VWS negotiates with pharmaceutical companies on the cost of new medicines.
HCV is routinely and nationally detected VISION
The GGD is in charge of finding patients who are out of sight.
HCV infections among migrants are detected using a screening programme.
Healthcare providers encourage risk groups to get screened for HCV, HBV, and HIV.
Healthcare providers use new technologies, for instance an app, to identify.
Prison physicians are encouraged to screen for HCV, HBV, and HIV and to set up a care plan.
The steering committee investigates how support for screenings among risk groups can be increased.
Healthcare providers register HCV infections in a national database.
Information lists 1a WHO, Factsheet Hepatitis C, 2014
4 RIVM, Infectious Diseases Bulletin, January 2014
1b Vriend et al., ‘Hepatitis C virus seroprevalence
5 CBS Statline 2014
in The Netherlands', European Journal of Public Health, 2012 6 National Healthcare Institute GIP data base
Netherlands, 2014 2 Centers for Disease Control and Prevention,
Yellow Book, Chapter 3, 2014 7 National Healthcare Institute GIP data base
Netherlands, 2014 3 Vriend et. al, ‘Hepatitis C virus prevalence in
The Netherlands: migrants account for most infections', Epidemiology and Infection, 2013 List of abbreviations DJI Custodial Institutions Agency GGD Public Health Service HBV Hepatitis B Virus HCV Hepatitis C Virus HIV Human Immunodeficiency Virus RIVM Netherlands National Institute for Public Health and the Environment VWS Netherlands Ministry of Public Health, Welfare and Sport The Argumentation Factory

Source: https://www.argumentenfabriek.nl/media/1886/13126-toekomst-hepatitis-c-boek_enrgb.pdf

buntschlin.ch

Il cour da las alps! Ideen, Produkte und Geschichten aus Tschlin – Strada – Martina Ideas, prodots ed istorgias da Tschlin – Strada – Martina Bun TschlinCH-7559 TschlinTel. +41 (0)81 866 33 03 Tschlin, Strada, Martina – Herz der Alpen! Tschlin, Strada, Martina – Il cour da las alps Das Dorf im Dreiländereck wo pfiffige Ideen nur so sprudelnIm untersten Unterengadin im Dreiländereck von Schweiz, Österreich und Italien liegt Tschlin wie auf einem Adlerhorst auf einer wunderschönen Sonnenterrasse hoch über dem Inn. Die zwei Fraktionen Strada und Martina liegen 400m weiter unten, sanft eingebettet ins Tal, direkt am Inn. In Tschlin gedeiht neben guten Einfällen auch die weit herum bekannte, biologische Biera Engiadinaisa. Andere hochwertige Produkte und Dienst-leistungen aus der Gemeinde, zusammengefasst unter dem Label Bun Tschlin, reichen vom hausgemachten Likör, edlem Schafmilchjogurt und Zie-genkäse bis zum Fleisch von schottischen Hochlandrindern.Abseits der grossen Touristenströme und doch in unmittelbarer Nähe des Skizentren Scuol, Samnaun-Ischgl, Nauders-Tirol und Schöneben im Vinschgau ist die Umgebung von Tschlin ein Paradies für Schneesportler. Auch im Sommer kommt der Wanderer von Tschlin aus auf Touren in allen Schwierigkeitsgraden auf seine Kosten. Für das Wohl der Gäste sorgen charmante kleine Pensionen und kreative Restaurants und es gibt einige Sehenswürdigkeiten zu entdecken. Tschlin bietet alles, was das Herz des ruhesuchenden Reisenden begehrt.

Doi:10.1016/j.mpsur.2007.10.013

The diabetic foot infection can lead to tissue necrosis and amputation. Diabetes is the leading non-traumatic cause of major amputation of the lower limbs. Miles J levyJonathan ValabhjiQ2 NeuropathyNerve damage due to disease of the vasa nervorum results in a ‘glove and stocking' sensorimotor peripheral neuropathy that may progress proximally. The motor component results in dener-vation of the small muscles of the foot, leading to: • hyperextension at the metatarsophalangeal joints