Epidemiology and Control of Hepatitis C Virus (Hcv) Infection in Brunei Darussalam: A Retrospective Cohort Study

Epidemiology and Control of Hepatitis C Virus (Hcv) Infection in Brunei Darussalam: A Retrospective Cohort Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Epidemiology and Control of Hepatitis C Virus (Hcv) Infection in Brunei Darussalam: A Retrospective Cohort Study Kai Shing Koh, Justin Wong, Liling Chaw This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5149746/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background We describe the epidemiology of hepatitis C virus (HCV) cases in Brunei Darussalam, and evaluated factors associated with HCV treatment initiation, completion, achieving sustained virologic response (SVR), baseline HCV-related complications, and HCV-related deaths. Methods A retrospective cohort study was conducted from January 2013 to December 2022 using data derived from EVYDENCE and the HCV registry to identify all diagnosed HCV cases in Brunei. Multivariable logistic regression was used to determine the associated factors. Results While incidence rates remained stable over a decade at below 20.0 per 100,000 population, we observed rising prevalence rates from 10.1 to 48.7 per 100,00 population in 2014 and 2022, respectively. Among 801 anti-HCV positive cases identified, 57% (n = 457) had detectable HCV RNA, 16.5% (n = 132) were HCV RNA negative, while 26.5% (n = 212) were not tested for HCV RNA. Treatment was initiated in 52.3% (n = 239) of HCV RNA positive cases, with higher odds among those aged 30–54 years [30–39 years (adjusted OR (aOR) = 2.41 (95% CI 1.17, 5.07)), 40–44 years (aOR = 2.55 (95% CI 1.19, 5.58)), 50–54 years (aOR = 2.76 (95% CI 1.25, 6.24))] and locals (aOR = 2.42 (95% CI 1.16, 5.36)). Cases diagnosed in 2020–2022 had lower odds of starting (aOR = 0.29 (95% CI 0.16, 0.51)) and completing (aOR = 0.16 (95% CI 0.05, 0.56)) treatment. Among 239 cases who initiated treatment, 69.5% (n = 166) completed treatment. 64.5% (n = 107) of these achieved SVR, with higher odds in cases diagnosed in 2018–2022 (aOR = 2.60 (95% CI 1.08, 6.90). 7.4% (n = 59) had HCV-related complications at baseline, with higher odds in those aged ≥ 50 (aOR = 3.32 (95% CI 1.93, 5.79). Among 129 deaths, 36.4% (n = 47) were HCV-related, of which 44.7% (n = 21) had HCV-related complications at baseline. Conclusions We observed rising HCV prevalence in Brunei, likely due to the decline in treatment initiation and completion. This reveals gaps in our HCV management and calls for actions to strengthen public health and clinical care strategies. Nearly half of the HCV deaths had baseline HCV-complications, highlighting the need for early screening and follow-up. Future studies should determine at-risk populations and explore barriers to HCV testing and care, to adequately address these issues and provide effective solutions. Hepatitis C virus epidemiology treatment mortality Brunei Figures Figure 1 Figure 2 Introduction As of June 2022, the World Health Organization (WHO) estimated that 58 million people worldwide have chronic hepatitis C virus (HCV) infection, with about 1.5 million new infections occurring annually.( 1 ) Globally, approximately 290,000 deaths in 2019 were HCV-related, with most deaths attributable to cirrhosis and hepatocellular carcinoma (HCC). In 2019, HCV accounted for 15.3 million global disability-adjusted life years (DALYs), with acute hepatitis, cirrhosis and liver cancer contributing 1.7%, 79.5%, and 18.8% to DALYs due to HCV, respectively.( 2 ) Among the WHO Western Pacific Region (WPR) countries, HCV accounted for 26% of all liver cancer deaths as well as 27% of deaths due to liver cirrhosis and other chronic liver disease (CLD) in the WHO WPR ( 3 , 4 ). In 2019, 25% of the top 20 countries globally for HCV-related deaths are within the WHO WPR.( 3 , 4 ) HCV is a ribonucleic acid (RNA) virus from the Flaviviridae family, has an incubation period of between 0.5 and 6 months, and can cause both acute and chronic infections.( 1 ) The virus can be transmitted through direct percutaneous exposure (such as sharing of contaminated needles among intravenous drug users), vertically from infected mother to child, and sexually (particularly among individuals with multiple sexual partners as well as among men who have sex with men).( 5 , 6 ) The antibody to HCV (anti-HCV) can be detected by enzyme immunoassay, and seroconversion typically occurs around 8–11 weeks after exposure, whereas HCV RNA is usually detectable earlier, within 1–2 weeks post exposure.( 6 , 7 ) For about 30% of HCV infected individuals, their immune system can spontaneously clear the virus within 6 months of infection without any treatment.( 1 ) This group of individuals would test positive for anti-HCV but negative for HCV RNA, and tend to be asymptomatic. The remaining 70% of individuals with HCV would go on to develop chronic infection, indicated by the presence of HCV RNA in their serum. Chronic HCV infection often remain undiagnosed until decades later when symptoms develop from the sequelae of HCV-related complications, such as chronic liver disease, liver cirrhosis and HCC.( 8 ) Pan-genotypic direct acting-antivirals (DAAs) are the recommended therapy for the treatment of HCV infection.( 1 ) The main aim of treatment is to achieve cure via elimination of the HCV virus, which is defined by the absence of detectable HCV RNA 6 months after treatment completion, also known as achieving sustained virologic response (SVR). SVR attainment has been associated with improvement in all-cause mortality, liver-related mortality, development of HCC as well as other hepatic-related complications.( 9 , 10 ) Brunei Darussalam (population 430,000) is a small country in Southeast Asia with an estimated HCV prevalence of 0.33% in 2022 using Markov model for HCV.( 11 ) HCV surveillance data (likely incomplete) is managed by Brunei’s Ministry of Health (MOH). However, to date, no studies have described the prevalence and natural history of HCV in the country. Previously published local HCV studies were primarily focussed on treatment response, genotyping or prevalence among a subgroup of patients.( 12 – 14 ) This study thus aims to describe the epidemiological and control indicators of HCV cases in Brunei Darussalam. Aggregating national surveillance data with data from the national electronic medical record system, we aim to: ( 1 ) determine the incidence and prevalence of HCV cases in the country, ( 2 ) identify the common possible sources of HCV transmission, ( 3 ) identify the determinants of HCV treatment initiation and cure, and lastly, ( 4 ) determine the factors associated with HCV-related complications and deaths. Our study findings could firstly narrow down the long list of countries with no HCV prevalence estimates regionally and globally, a threat recognised by the WHO.( 15 , 16 ) Secondly and more importantly, it could also inform stakeholders on the scale of this issue, and determine possible ways to address the issue in the national context. Our findings could allow decision makers to estimate the number of people requiring HCV treatment, for HCV resource planning and allocation, and to assess the needs for screening and testing in targeted population groups. Methods We conducted a retrospective cohort study where all diagnosed HCV cases in Brunei Darussalam from January 2013 to December 2022 (10 years) were included. An HCV case is defined as one whose serum sample collected has the presence of anti-HCV. We have included all HCV cases regardless of existing co-morbidities or presence of co-infection with human immunodeficiency virus (HIV) or hepatitis B virus (HBV). Case reporting, testing & investigation In Brunei, HCV screening via detection of the presence of anti-HCV in blood samples is performed for occupational health screening including for healthcare professionals and for pre-employment medical fitness for government employees and foreign workers, for patients with end-stage renal failure (ESRD) undergoing haemodialysis, as well as for donated blood and blood products.( 12 , 14 ) Additionally, screening for HCV may be conducted in the clinical settings when patients present with suspected liver pathology, and in patients with cancers prior to initiating chemotherapy. HCV is a notifiable disease under Brunei’s Infectious Disease Act since 2003.( 17 ) Healthcare professionals from both public and private health facilities in the country are mandated to report all positive anti-HCV cases to the Brunei Centre for Disease Control and Prevention (Brunei CDC), MOH. Once reported, counselling of the cases and active case investigations are conducted by Brunei CDC to identify possible sources of transmission as well as any high-risk close contacts. All HCV cases will be referred to the Hepatology Clinic for further evaluation and management.( 14 ) Only HCV cases with detectable HCV RNA (indicating chronic infection) will be offered HCV treatment. Investigations and treatment are free at point-of-care. For identified close contacts, the source case will usually provide their details and relay the information for blood HCV screening, after which the results will be traced by Brunei CDC. If negative, no follow-up will be required, whereas if positive for anti-HCV, they will be contacted and counselled as per a confirmed case of HCV. In instances where the close contacts did not attend HCV screening, the source case will be contacted and reminded. However, it is voluntary whether the index cases inform their close contacts and whether their close contacts agree to undergo HCV screening. Data collection and case identification To ensure completeness in case detection, data for this study were obtained from two sources: ( 1 ) EVYDENCE, and ( 2 ) the HCV registry. EVYDENCE is a digital platform that integrates data from several national databases, primarily, the national e-health records system, the Brunei Health Information Management System database (Bru-HIMS), a one-patient-one-record system linking primary and secondary care clinical records, and laboratory and radiological investigations that covers > 99% of the population and was first introduced in government health centres and hospitals in 2013.( 18 , 19 ) The HCV registry is a manual, offline registry maintained by Brunei CDC comprising of all notified HCV cases in Brunei. EVYDENCE includes data from 2013 whereas the HCV registry only comprises HCV cases from 2017 as those prior to 2017 could not be traced. Data collected from EVYDENCE include socio-demographics (age, gender, nationality, ethnicity, district of residence), year of first anti-HCV positive, HCV treatment initiation and completion, HCV RNA level 6 months post treatment, complications related to HCV at diagnosis, as well as deaths related to HCV. For HCV-related complications, further information was collected to identify the type of complications, which include chronic liver disease, liver fibrosis and/or cirrhosis, liver failure, and liver carcinoma. Similarly further data was collected for type of HCV-related deaths, including liver cirrhosis, liver failure, and liver carcinoma. Data collected from the HCV registry include socio-demographics (age, gender, nationality, ethnicity, district of residence), source of HCV acquisition, and year registered as positive HCV case. Incomplete data were manually searched for in Bru-HIMS using the cases’ unique personal identifier. Duplicate cases from the two data sources were identified and removed. Data analysis First, descriptive statistics was used to report the socio-demographics of all HCV cases included in the study. Using the WHO monitoring and evaluation framework for viral hepatitis as a guide, we reported our outcomes of interest using ( 1 ) indicators related to treatment and care, including HCV treatment initiation and completion, and SVR attainment, ( 2 ) indicators related to morbidity, including incidence and prevalence, and HCV-related complications at diagnosis, and ( 3 ) indicators related to mortality, including HCV-related deaths.( 20 ) We calculated the incidence based on the number of new HCV cases during the study period. Annual prevalence was calculated by adding the total number of cases with detectable HCV RNA by the end of the previous year to the number of new cases with detectable HCV RNA in the current year, minus the number of deceased and cured cases from the current year. Paucity of data prior to 2013 means we could not estimate HCV prevalence in 2013. Both incidence and prevalence were reported as rates per 100,000 population. Patients were considered to have initiated treatment when antiviral therapy for HCV had been prescribed on Bru-HIMS, while patients were considered to have completed treatment if HCV RNA test was performed 6 months after treatment completion to assess for SVR. Patients were considered to have attained SVR if HCV RNA 6 months or more post treatment completion was undetectable. Patients who were found to have HCV-related complications including liver cirrhosis, liver failure and liver carcinoma within one year of their HCV diagnosis were considered to have HCV-related complications at baseline. HCV-related deaths referred to patients who died due to HCV-related causes including liver cirrhosis, liver failure and liver carcinoma. Logistic regression was used to determine the association between sociodemographic factors and HCV diagnosis year groups with HCV treatment initiation, treatment completion, attainment of SVR, HCV-related complications at baseline as well as deaths due to HCV. All analyses were performed using R ver. 4.2.3.( 21 ) We considered p < 0.05 was considered as statistically significant. The total number of HCV cases were different for the logistic regression analyses in this study as those with missing data were removed by default. To avoid reporting bias, the overall proportions were reported based on the total identified cases. Result A total of 841 HCV cases were identified from EVYDENCE (n = 813) and the HCV registry (n = 28), between January 2013 and December 2022 (10 years), and January 2017 to December 2022 (6 years) respectively. Duplicate records (n = 23), records with discrepancy in year of diagnosis and date of HCV treatment initiation or diagnosis of complication (n = 14), one case with wrong personal identifier (n = 1), and patients with no evidence of HCV positive results in Bru-HIMS (n = 2) were excluded from the study. The final dataset consisted of 801 HCV cases (Fig. 1 ). Incidence and prevalence The annual incidence rates of HCV cases were highest in 2013 and 2014 at 28.8 and 31.2 per 100,000 population, respectively (Fig. 2 ). It then trended downward and remained fairly stable at under 20.0 per 100,000 population, with a slight decline after 2019. On the other hand, the annual prevalence rate was observed to gradually increase from 10.1 per 100,000 population in 2014 to 48.7 per 100,000 population in 2022. Characteristics of HCV cases The mean age of the HCV cases was 43.3 years (95% CI 42.5, 44.2) and men comprised majority of the cases (662, 82.6%) (Table 1 ). Citizens and permanent residents (691, 86.3%) made up a large proportion of the cases. Malay patients consisted more than half of the HCV cases (530, 66.3%). Most of the HCV cases resided in the Brunei-Muara (359, 44.8%) and Belait (329, 41.1%) districts. The source of HCV acquisition included mother-to-child transmission (1, 0.1%) and sexual intercourse (1, 0.1%), however the source for most the cases were either unknown or not available (799, 99.8%). Among these HCV cases, 457 (57.0%) had detectable HCV RNA while 212 (26.5%) were not tested. Treatment initiation and outcomes Among patients with positive HCV RNA (n = 457), treatment was initiated in 239 (52.3%) cases (table S1 ). Cases of age-groups 30–39 years (adjusted OR (aOR) = 2.41 (95% CI 1.17, 5.07)), 40–44 years (aOR = 2.55 (95% CI 1.19, 5.58)) and 50–54 years (aOR = 2.76 (95% CI 1.25, 6.24)) had higher odds of starting HCV treatment when compared with those < 30 years old (Table 2 ). Locals had 2.42 times higher odds of starting treatment for HCV compared to foreign residents (aOR = 2.42 (95% CI 1.16, 5.36)). HCV cases diagnosed in 2020–2022 had lower odds of starting treatment (aOR = 0.29 (95% CI 0.16, 0.51)) compared with cases diagnosed in 2013–2014. Among cases who initiated treatment (n = 239), 166 (69.5%) completed treatment (table S1 ). HCV cases diagnosed in 2020–2022 were found to have lower odds of completing treatment (aOR = 0.16 (95% CI 0.05, 0.56)) compared to cases diagnosed in 2013–2014 (Table 3 ). Among those who completed HCV treatment (n = 166), 107 (64.5%) achieved SVR (table S1 ). Higher odds of SVR attainment were found among HCV cases diagnosed in 2018–2022 compared to those that were diagnosed earlier in 2013–2017 (aOR = 2.60 (95% CI 1.08, 6.90), Table 4 ). Among the HCV cases (n = 801), 59 (7.4%) were observed to have HCV-related complications at the time of diagnosis of HCV infection (table S1 ). Those aged ≥ 50 had 3.32 times higher odds of having complication at baseline compared to those < 50 years old (aOR = 3.32 (95% CI 1.93, 5.79), Table 5 ). Among HCV cases who died (n = 129), 47 (36.4%) were found to be related to HCV (table S1 ). Among the HCV-related deaths, 12 (25.5%) started treatment, 5 (12.6%) completed treatment, while 2 (4.3%) were cured (Fig. 1 ). Twenty-one (44.7%) of the HCV-related deaths had HCV-related complications at baseline (Fig. 1 ). We did not observe any association between socio-demographic factors and HCV-related deaths (Table 5 ). Table 1 Characteristics of HCV cases from 2013 to 2022, Brunei Positive anti-HCV HCV RNA detected (n = 801) Patient characteristics Total (%) Yes (%) No (%) Not done (%) Total 801 457 (57.0) 132 (16.5) 212 (26.5) Mean age (SD) 43.3 (12.16) 43.8 (11.0) 45.5 (12.0) 41.0 (14.2) Median age (IQR) 44.0 (35–51) 44.0 (37–51) 47.0 (40–52) 41.0 (32–50) Age range (years) 0.0 to 83.0 6.0 to 77.0 0.0 to76.0 0.0 to 83.0 Age group (years) 0–29 98 (12.2) 49 (10.7) 12 (9.1) 37 (17.5) 30–39 185 (23.1) 107 (23.4) 18 (13.6) 60 (28.3) 40–44 134 (16.7) 79 (17.3) 23 (17.4) 32 (15.1) 45–49 143 (17.9) 84 (18.4) 31 (23.5) 28 (13.2) 50–59 188 (23.5) 112 (24.5) 37 (28.0) 39 (18.4) 60+ 53 (6.6) 26 (5.7) 11 (8.4) 16 (7.5) Gender Male 662 (82.6) 369 (80.7) 110 (83.3) 183 (86.3) Female 139 (17.4) 88 (19.3) 22 (16.7) 29 (13.7) Nationality Local 691 (86.3) 418 (91.5) 122 (92.4) 151 (71.2) Foreign 110 (13.7) 39 (8.5) 10 (7.6) 61 (28.8) Ethnicity Malay 530 (66.3) 312 (68.3) 96 (72.7) 122 (57.6) Chinese 54 (6.7) 29 (6.3) 8 (6.1) 17 (8.0) Others 78 (9.7) 33 (7.2) 17 (12.9) 28 (13.2) Unknown 139 (17.3) 83 (18.2) 11 (8.3) 45 (21.2) District of residence Brunei-Muara 359 (44.8) 195 (42.7) 62 (47.0) 102 (48.1) Belait 329 (41.1) 198 (43.4) 49 (37.1) 82 (38.7) Temburong 11 (1.4) 5 (1.1) 3 (2.3) 3 (1.4) Tutong 102 (12.7) 59 (12.9) 18 (13.6) 25 (11.8) Year of diagnosis 2013–2014 243 (30.3) 143 (31.3) 47 (35.6) 53 (25.0) 2015–2016 177 (22.2) 86 (18.8) 36 (34.9) 45 (21.2) 2017–2019 211 (26.3) 128 (28.0) 32 (24.2) 51 (24.1) 2020–2022 170 (21.2) 100 (21.9) 7 (5.3) 63 (29.7) HCV, hepatitis C virus; RNA, ribonucleic acid. Table 2 Factors associated with HCV treatment initiation among HCV cases with detectable HCV RNA, Brunei HCV treatment initiated Yes (n = 239) n (%) No (n = 218) n (%) Crude OR (95% CI) Adjusted OR (95% CI) Age group (years) 0–29 18 (7.5) 31 (14.2) 1 1 30–39 60 (25.1) 47 (21.6) 2.20 (1.11, 4.47) 2.41 (1.17, 5.07) 40–44 48 (20.1) 31 (14.2) 2.67 (1.29, 5.65) 2.55 (1.19, 5.58) 45–49 49 (20.5) 35 (16.1) 2.41 (1.18, 5.05) 2.11 (1.00, 4.53) 50–54 38 (15.9) 28(12.8) 2.34 (1.10, 5.06) 2.76 (1.25, 6.24) ≥ 55 26 (10.9) 46 (21.1) 0.97 (0.46, 2.08) 1.10 (0.50, 2.45) Gender Male 201 (84.1) 168 (77.1) 1.57 (0.99, 2.53) 1.46 (0.88, 2.45) Female 38 (15.9) 50 (22.9) 1 1 Nationality Local 228 (95.4) 190 (87.2) 3.05 (1.52, 6.56) 2.42 (1.16, 5.36) Foreign 11 (4.6) 28 (12.8) 1 1 Year of diagnosis 2013–2014 88 (36.8) 55 (25.2) 1 1 2015–2016 55 (23.0) 31 (14.2) 1.11 (0.64, 1.94) 1.13 (0.63, 2.03) 2017–2019 65 (27.2) 63 (28.9) 0.64 (0.40, 1.04) 0.65 (0.39, 1.08) 2020–2022 31 (13.0) 69 (31.7) 0.28 (0.16, 0.48) 0.29 (0.16, 0.51) HCV, hepatitis C virus; RNA, ribonucleic acid. Table 3 Factors associated with HCV treatment completion among cases who initiated HCV treatment (n = 209 out of 239 (87.4%)) HCV treatment completed Yes (n = 166) n (%) No (n = 43) n (%) Crude OR (95% CI) Adjusted OR (95% CI) Age group (years) 0–29 11 (6.6) 4 (9.3) 1 1 30–39 43 (25.9) 10 (23.2) 1.56 (0.37, 5.73) 1.79 (0.40, 7.00) 40–44 34 (20.5) 7 (16.3) 1.77 (0.40, 7.08) 1.88 (0.41, 7.95) 45–49 39 (23.5) 6 (14.0) 2.36 (0.53, 9.86) 2.27 (0.49, 9.76) ≥ 50 39 (23.5) 16 (37.2) 0.89 (0.23, 3.87) 1.06 (0.25, 3.85) Gender Male 142 (85.5) 36 (83.7) 1.15 (0.22, 3.04) 1.09 (0.39, 2.80) Female 24 (14.5) 7 (16.3) 1 1 Nationality Local 161 (97.0) 40 (93.0) 2.42 (0.48, 10.26) 2.38 (0.43, 11.13) Foreign 5 (3.0) 3 (7.0) 1 1 Year of diagnosis 2013–2014 72 (43.4) 13 (30.2) 1 1 2015–2016 43 (25.9) 10 (23.3) 0.78 (0.31, 1.96) 0.81 (0.32, 2.11) 2017–2019 45 (27.1) 12 (27.9) 0.68 (0.28, 1.63) 0.72 (0.30, 1.78) 2020–2022 6 (3.6) 8 (18.6) 0.14 (0.04, 0.45) 0.16 (0.05, 0.56) HCV, hepatitis C virus. Table 4 Factors associated with SVR attainment among patients who completed HCV treatment SVR achieved Yes (n = 107) n (%) No (n = 59) n (%) Crude OR (95% CI) Adjusted OR (95% CI) Age group (years) 0–29 6 (5.6) 5 (8.5) 1 1 30–39 28 (26.2) 15 (25.4) 1.56 (0.39, 6.03) 1.16 (0.28, 4.62) 40–44 27 (25.2) 7 (11.9) 3.21 (0.74, 14.12) 2.35 (0.52, 10.65) 45–49 26 (24.3) 13 (22.0) 1.67 (0.41, 6.59) 1.42 (0.35, 5.69) ≥ 50 20 (18.7) 19 (32.2) 0.88 (0.22, 3.39) 0.60 (0.14, 2.42) Gender Male 94 (87.9) 48 (81.4) 1.66 (0.68, 3.98) 1.61 (0.62, 4.14) Female 13 (12.1) 11 (18.6) 1 1 Nationality Local 103 (96.3) 58 (98.3) 0.44 (0.02, 3.09) 0.41 (0.02, 3.46) Foreign 4 (3.7) 1 (1.7) 1 1 Year of diagnosis 2013–2017 79 (73.8) 51 (86.4) 1 1 2018–2022 28 (26.2) 8 (13.6) 2.26 (0.99, 5.66) 2.60 (1.08, 6.90) HCV, hepatitis C virus; RNA, ribonucleic acid. Table 5 Factors associated with presence of HCV-complications at diagnosis among HCV cases and HCV-related deaths among HCV cases who died, Brunei Had HCV-related complications at diagnosis (n = 801) Died due to HCV (n = 129) Yes (n = 59) n (%) No (n = 742) n (%) Crude OR (95% CI) Adjusted OR (95% CI) Yes (n = 47) n (%) No (n = 82) n (%) Crude OR (95% CI) Adjusted OR (95% CI) Age group (years) < 50 25 (42.4) 535 (72.1) 1 1 17 (36.2) 31 (37.8) 1 1 ≥ 50 34 (57.6) 207 (27.9) 3.51 (2.05, 6.09) 3.32 (1.93, 5.79) 30 (63.8) 51 (62.2) 1.07 (0.51, 2.28) 0.96 (0.44, 2.12) Gender Male 44 (74.6) 618 (83.3) 0.59 (0.32, 1.12) 0.72 (0.39, 1.39) 30 (63.8) 59 (72.0) 0.69 (0.32, 1.49) 0.66 (0.29, 1.48) Female 15 (25.4) 124 (16.7) 1 1 17 (36.2) 23 (28.0) 1 1 Nationality Local 55 (93.2) 636 (85.7) 2.29 (0.92, 7.68) 2.06 (0.81, 6.98) 45 (95.7) 80 (97.6) 0.56 (0.07, 4.82) 0.51 (0.06, 4.46) Foreign 4 (6.8) 106 (14.3) 1 1 2 (4.3) 2 (2.4) 1 1 Year of diagnosis 2013–2017 34 (57.6) 450 (60.6) 1 1 35 (74.5) 63 (76.8) 1 1 2018–2022 25 (42.4) 292 (39.4) 1.13 (0.66, 1.93) 1.12 (0.64, 1.92) 12 (25.5) 19 (23.2) 1.14 (0.49, 2.59) 1.12 (0.47, 2.60) HCV, hepatitis C virus; RNA, ribonucleic acid. Discussion Our study findings revealed several key points highlighting the need for better control of HCV cases in Brunei Darussalam. First is the increasing prevalence, indicating that the number of cases living with chronic HCV infection in the country are increasing. Second is the significant proportion of HCV cases who were not tested for HCV RNA, the step needed to initiate treatment in the first place. Finally, is the increased mortality among those with baseline HCV-related complications. The increasing prevalence observed could be due to the downward trend in both HCV treatment initiation and completion during the study period. In Brunei, pegylated interferon-alpha was the main treatment of choice for HCV until 2018 when DAA was first introduced. However, both therapies were under named-patient basis (NPB) which required authorization for procurement and dispensing, and the administrative procedure could be time-consuming. Furthermore, the availability of these medications from pharmacy was not consistent due to internal procurement processes. The inadvertent delays and disruption in treatment could have resulted in negative perception of healthcare providers by patients leading to distrust and subsequent default and loss to follow-up.( 30 , 31 ) This suggests the need to explore how medication supply can be improved and how clinical management of HCV cases can be enhanced to ensure timely follow-up and medication adherence. Although DAA was removed from the NPB list since 2020 making it more accessible, this coincided with the COVID-19 pandemic which affected routine healthcare services including patient follow-up and could have further amplified the issues with HCV treatment initiation and completion during this time.( 22 , 23 ) We also found that more than a quarter of new HCV cases were not tested for HCV RNA, and that more than three-quarters of them were locals. This could be due to several reasons. First, the positive anti-HCV results could be missed by the attending physicians. Second, the new HCV cases were not notified to Brunei CDC hence no consultation and onward referral to the Hepatology Clinic for HCV RNA testing was arranged. Third, patients failed to attend their appointments at the Hepatology Clinic. This may indicate that the HCV prevalence could be higher that what we have reported due to these HCV cases with unknown HCV RNA status. Notably, HCV treatment for locals is available for free, hence monetary cost is not a barrier to testing. Thus, this missed opportunity to test for HCV RNA among new HCV cases is concerning and warrants actions from both public health authorities and clinicians to ensure more stringent protocols are in place for follow-up and further testing of new HCV cases. Previous studies reported HCV treatment initiation rates among HCV RNA-positive patients ranging from 20% to over 60%, while we reported a rate of around 50%.( 24 – 26 ) This can be attributed to access to care, affordability of HCV treatment, whether treatment was received at primary care or gastroenterology clinic, and changes in HCV treatment policies. While our study did not evaluate these factors, we found that HCV patients aged < 55 generally had higher odds of starting treatment. This could be due to the younger age groups’ eligibility as treatment candidate as they would have less co-morbidities and concerns of treatment side effects when compared to elderly patients.( 27 , 28 ) Around 30% of our study patients were aged 50 years and above, and this group had higher odds of having HCV-related complications at baseline, which could have hindered them from commencing treatment. Our study did not find any significant association between HCV-related deaths and sociodemographic factors. Other studies have previously identified clinical factors such as failure to achieve SVR, presence of severe liver disease at baseline, and HCV viraemia (detectable HCV RNA) to be significantly associated with mortality due to HCV.( 27 – 29 ) Although these were not included in our analysis, we found that nearly 50% of our cases who died due to HCV had baseline HCV-related complications, suggesting a need to promote early screening and adequate follow-up for new HCV cases with HCV-related complications. One major strength of our study is the utilization of a national electronic health records system for case identification, in addition to the offline HCV registry. This allowed for a more comprehensive capture of all anti-HCV and HCV RNA positive patients in Brunei to provide better estimates of the population incidence and prevalence of HCV cases, respectively. Second, this study revealed the limitations of our offline HCV registry as seen in the discrepancy in the number of cases captured from EVYDENCE compared to the HCV registry and exposed the shortfall in mandatory reporting of HCV cases in the country. However, this provides a strong rationale to migrate to an online-based registry in order to have a more complete HCV case detection. This study has several limitations. First, the prevalence cases in 2013 could not be determined while the incidence cases could have been overestimated. During the adoption of Bru-HIMS in 2013, all new and old HCV cases who had a positive anti-HCV test result in that year were captured as new. Because we could not obtain surveillance data prior to 2013, we were unable to differentiate between the new and old cases in that year. Second, data extraction using ICD-10 codes relied on clinicians’ input of the codes as well as the correct ICD-10 codes being entered in order for the intended information, such as types of complication, to be extracted. This may result in underestimation of the HCV complications at baseline if ICD-10 were incorrectly or not recorded. Third, only deaths recorded on Bru-HIMS were included in this study. Deaths from the community were not captured as these were not reflected in their clinical records, therefore the death figures obtained from this study may be underreported. Fourth, although HCV is known to be prevalent among key population groups such as people who inject drugs (PWID) and prisoners, we could not obtain data on the source of HCV acquisition and incarceration history among the HCV cases due to limitation in data extraction.( 30 , 31 ) Lastly, the present study did not include HCV genotypes, types of treatment, and presence of other co-morbidities or co-infection with HIV or HBV in the analyses which may better reflect the association with the outcomes of interest. Here we identified several avenues for future research. First, improvement in data extraction to quantify source of HCV acquisition and access to information on whether cases are currently incarcerated would allow for future analyses of at-risk population groups and assess whether tailored HCV management is needed for these groups. Second, further investigation is needed to determine why new HCV cases could be missed for HCV RNA testing. Third, more in-depth evaluation is warranted to explore other possible factors that may have contributed to the observed downward trends in treatment completion and initiation. Determining the reasons behind these are crucial to help identify potential barriers in HCV management so that more appropriate and applicable solutions can be implemented. Conclusions In conclusion, our study highlights a rising HCV prevalence likely due to decreasing trends in treatment initiation and completion which underscores gaps in our local HCV management, suggesting the need to review follow-up protocols as well as medication procurement processes and supply chain. More than a quarter of new cases were not tested for HCV RNA, which may indicate a higher HCV prevalence than what we have reported and calls for actions to improve existing guidelines for HCV RNA testing among new HCV cases. We found that nearly 50% of patients who died from HCV had complications at baseline, emphasizing the need for early screening and thorough follow-up. We recommend more comprehensive data collection and analyses in future studies that would better capture at-risk population groups to formulate targeted strategies and interventions. In-depth exploration of challenges to HCV testing and treatment is also crucial to address potential barriers and develop effective solutions. Abbreviations anti-HCV Antibodies against hepatitis C virus Brunei CDC Brunei Centre for Disease Control and Prevention Bru-HIMS Brunei Health Information Management System database CLD Chronic liver disease DAA Direct acting-antivirals DALYs Disability-adjusted life years ESRD End-stage renal failure HBV Hepatitis B virus HCV Hepatitis C virus HCC Hepatocellular carcinoma HIV Human immunodeficiency virus MOH Ministry of Health NPB Named-patient basis PWID People who inject drugs RNA Ribonucleic acid SVR Sustained virologic response WPR Western Pacific Region WHO World Health Organization Declarations Ethics approval and consent to participate This study involves human participants and was approved by Ethical committee name: Joint Research Ethics Committee of PAPRSB Institute of Health Science (IHSREC) and Medical and Health Research Ethics (MHREC), UBD Reference no: UBD/PAPRSBIHSREC/2023/31. Informed consent was waived as study involves the use of retrospectively collected patient data recorded by the Ministry of Health for the purposes of investigations related to HCV (in accordance with the Infectious Disease Act). Consent for publication Not applicable. Competing interests The authors declare that they have no competing interests. Funding Not applicable. Author Contribution KSK and JW conceived the study. KSK analysed the data and drafted the manuscript. KSK and LC interpreted the results. All authors read, revised and approved the manuscript. Acknowledgement The authors would like to thank Lee Thian Hui, Shannon Newn, Liwani Nursyafiqah Bahari and Lim Sheau Ling from EVYD Technology Limited for assisting with data extraction from EVYDENCE, as well as Brunei CDC for providing data from the HCV registry. The authors are also grateful to Dr Chong Vui Heng and Dr Kyaw Thu for their technical expertise in this manuscript. Data Availability Data used during this in are available from the corresponding author upon reasonable request. References World Health Organization, Hepatitis C. 2024. https://www.who.int/news-room/fact-sheets/detail/hepatitis-c . Accessed 17 Jul 2024. Institute for Health Metrics and Evaluation. Total burden related to hepatitis C. Washington: Institute for Health Metrics and Evaluation. 2022. https://www.healthdata.org/results/gbd_summaries/2019/total-burden-related-to-hepatitis-c-level-3-cause 1027.pdf . Accessed 17 Oct 2022. World Health Organization Western Pacific Region. Regional hepatitis data. https://www.who.int/westernpacific/health-topics/hepatitis/regional-hepatitis-data . Accessed 18 Oct 2022. Coalition for Global Hepatitis Elimination. Interim report: progress towards HBV and HCV elimination in the Western Pacific Region. Georgia: Coalition for Global Hepatitis Elimination. 2021. https://www.globalhep.org/interim-report-progress-towards-hbv-and-hcv-elimination-western-pacific-region . Accessed 10 Jan 2023. Alter MJ. Epidemiology of hepatitis C virus infection. World J Gastroenterol. 2007;13(17):2436–41. Centers for Disease Control and Prevention. Hepatitis C questions and answers for health professionals. US: Centers for Disease Control and Prevention. 2020. https://www.cdc.gov/hepatitis/hcv/hcvfaq.htm . Accessed 8 Dec 2022. Chen SL, Morgan TR. The natural history of hepatitis C virus (HCV) infection. Int J Med Sci. 2006;3(2):47–52. Laraque F, Varma JK. A public health approach to hepatitis C in an urban setting. Am J Public Health. 2017;107(6):922–6. Ng V, Saab S. Effects of a sustained virologic response on outcomes of patients with chronic hepatitis C. Clin Gastroenterol Hepatol. 2011;9(11):923–30. Veldt BJ, Heathcote EJ, Wedemeyer H, Reichen J, Hofmann WP, Zeuzem S, et al. Sustained virologic response and clinical outcomes in patients with chronic hepatitis C and advanced fibrosis. Ann Intern Med. 2007;147(10):677–84. Coalition for Global Hepatitis Elimination. Brunei Darussalam. Georgia: Coalition for Global Hepatitis Elimination. 2023. https://www.globalhep.org/data-profiles/countries/brunei-darussalam . Accessed 24 Sep 2024. Chong VH, Zinna HS. Hepatitis C virus infection and haemodialysis: experience of a district general hospital in Brunei Darussalam. Singap Med J. 2008;49(11):916–20. Chong VH, Jamaludin AZF, Alexander MJ, Jacob AP, Jalihal A. Chronic hepatitis C treatment response to combination therapy: experience of RIPAS Hospital. Brunei Int Med J. 2010;6(2):92–7. Chong VH, Jamaludin AZF, Jalihal A. Hepatitis C in Brunei Darussalam: a genotypic study. J Gastroenterol Hepatol. 2006;21:A19. World Health Organization. Global health sector strategies on, respectively, HIV, viral hepatitis and sexually transmitted infections for the period 2022–2030. Geneva: World Health Organization. 2022. https://apps.who.int/iris/handle/10665/362227 . Accessed 17 Oct 2022. Iversen J, Wand H, Chan PL, Le LV, Maher L. Systematic review of hepatitis C virus prevalence in the WHO Western Pacific Region. Viruses. 2022;14(7):1548. Laws of Brunei. Chapter 204 Infectious Diseases. 2010. https://www.agc.gov.bn/AGCImages/LAWS/ACT_PDF/ . Accessed 3 Jan 2023. Koh KS, Lim HS, Lim J, Wei Y, Minn PW, Wong J. Development and implementation of a national mobile health application: a case study from Brunei. J Glob Health. 2022;12:03083. Ministry of Health Brunei. Bru-HIMS. Brunei: Ministry of Health. 2020. https://www.moh.gov.bn/SitePages/Bru-HIMS.aspx . Accessed 10 Jan 2023. World Health Organization. WHO monitoring and evaluation for viral hepatitis B and C: recommended indicators and framework. Geneva: World Health Organization. 2016. https://apps.who.int/iris/handle/10665/204790 . Accessed 21 Oct 2023. R Core Team. (2022). R: a language and environment for statistical computing. Austria: R Foundation for Statistical Computing. 2022. https://www.r-project.org/ . Accessed 10 Jan 2023. den Boogert EM, Veldhuijzen IK, Generaal E, Prins M, Sonneveld MJ, van der Meer AJ, et al. Substantial impact of the COVID-19 pandemic on the reported number of diagnosed chronic hepatitis C virus infections in the Netherlands, 2019–2021. BMC Public Health. 2023;23(1):1244. Kaufman HW, Bull-Otterson L, Meyer WA, Huang X, Doshani M, Thompson WW, et al. Decreases in hepatitis C testing and treatment during the COVID-19 pandemic. Am J Prev Med. 2021;61(3):369–76. Nguyen VH, Kam L, Yeo YH, Huang DQ, Henry L, Cheung R, et al. Characteristics and treatment rate of patients with hepatitis C virus infection in the direct-acting antiviral era and during the COVID-19 pandemic in the United States. JAMA Netw Open. 2022;5(12):e2245424. Zhang C, Lu J, Zhang Y, He P, Xia J, Huang M. Prevalence, diagnosis, treatment, and associated factors of hepatitis C in the United States from 1999 to 2018: a population-based cross-sectional study. Liver Res. 2022;6(4):284–8. Kapadia SN, Zhang H, Gonzalez CJ, Sen B, Franco R, Hutchings K, et al. Hepatitis C treatment initiation among US medicaid enrollees. JAMA Netw Open. 2023;6(8):e2327326. Piselli P, Serraino D, Fusco M, Girardi E, Pirozzi A, Toffolutti F, et al. Hepatitis C virus infection and risk of liver-related and non-liver-related deaths: a population-based cohort study in Naples, southern Italy. BMC Infect Dis. 2021;21:667. Singal AG, Volk ML, Jensen D, et al. A sustained viral response is associated with reduced liver-related morbidity and mortality in patients with hepatitis C virus. Clin Gastroenterol Hepatol. 2010;8(3):280–8. 288.e1. Uto H, Stuver SO, Hayashi K, Kumagai K, Sasaki F, Kanmura S, et al. Increased rate of death related to presence of viremia among hepatitis C virus antibody-positive subjects in a community-based cohort study. Hepatology. 2009;50(2):393–9. Jiang N, Bruneau J, Makarenko I, Minoyan N, Zang G, Høj SB, et al. HCV treatment initiation in the era of universal direct acting antiviral coverage – improvements in access and persistent barriers. Int J Drug Policy. 2023;113:103954. Nelson P, Mathers B, Cowie B, Hagan H, Jarlais DD, Horyniak D, et al. The epidemiology of viral hepatitis among people who inject drugs: results of global systematic reviews. Lancet. 2011;378(9791):571–83. Additional Declarations No competing interests reported. Supplementary Files Supplementarytable.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5149746","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":385455352,"identity":"42caad49-f71e-4b9a-99fd-a924bd977eeb","order_by":0,"name":"Kai Shing Koh","email":"","orcid":"","institution":"Ministry of Health","correspondingAuthor":false,"prefix":"","firstName":"Kai","middleName":"Shing","lastName":"Koh","suffix":""},{"id":385455356,"identity":"fca7088d-4d56-40c3-adfe-ac5d7186495e","order_by":1,"name":"Justin Wong","email":"","orcid":"","institution":"Ministry of Health","correspondingAuthor":false,"prefix":"","firstName":"Justin","middleName":"","lastName":"Wong","suffix":""},{"id":385455358,"identity":"16a6ed04-3a0c-4ff5-94fe-14a6f6acb3c1","order_by":2,"name":"Liling Chaw","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA5UlEQVRIiWNgGAWjYBACPmbmhgMghgEDA+MDxgZmIDOBgRmfFjZmRrgWZgPitDAwNjBAtbBJEKeFnbHxcMEvBnlz9jNm1bw7rBn42XMMmAt34HfY4Zl9DIY7e3LMbvOeSWeQ7HljwDzzDAEtvD0MCQYHcrfd5m07zGBwA2gLbxsxWs6/3VYM0mJPlBaeH0AtN3K3MYNtkSDKlgYJww033n+WnHsmnUfizLOCwzPxaOHnP3z4M88fG3mD82mJH97usJbjb0/e+LgQjxYwYGyTgLN5QMQBAhqA4A9hJaNgFIyCUTCCAQDQm0yFQiauQAAAAABJRU5ErkJggg==","orcid":"","institution":"Universiti Brunei Darussalam","correspondingAuthor":true,"prefix":"","firstName":"Liling","middleName":"","lastName":"Chaw","suffix":""}],"badges":[],"createdAt":"2024-09-25 07:23:07","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5149746/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5149746/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":73859492,"identity":"79f26f08-60bc-4e63-b9ed-e75989b627aa","added_by":"auto","created_at":"2025-01-15 10:48:58","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":47556,"visible":true,"origin":"","legend":"\u003cp\u003eStudy flow chart. HCV, hepatitis C virus; RNA, ribonucleic acid; SVR, sustained virologic response. Baseline HCV-related complications: patients who were found to have HCV-related complications including liver cirrhosis, liver failure and liver carcinoma within one year of their HCV diagnosis; HCV-related deaths: patients who died due to HCV-related causes including liver cirrhosis, liver failure and liver carcinoma.\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-5149746/v1/41bbf9ac386db2ba52bb08e3.png"},{"id":73861398,"identity":"dc263a2a-539c-491e-9550-f1737a9be313","added_by":"auto","created_at":"2025-01-15 11:04:58","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":26187,"visible":true,"origin":"","legend":"\u003cp\u003eAnnual HCV incidence and prevalence from 2013 to 2022, Brunei. HCV, hepatitis C virus.\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-5149746/v1/090b4d5d7e0a1130eeb45a18.png"},{"id":92381810,"identity":"7f839884-65b5-4475-94c6-ee9fa8fb4726","added_by":"auto","created_at":"2025-09-29 06:23:50","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1398251,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5149746/v1/60d17a33-7bc0-4d49-8d96-9e613d1cc6aa.pdf"},{"id":73861051,"identity":"fc3ec8b5-14cc-406f-8ecb-d2e234eddd4c","added_by":"auto","created_at":"2025-01-15 10:56:58","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":19726,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementarytable.docx","url":"https://assets-eu.researchsquare.com/files/rs-5149746/v1/8d84c249aa3fd2c8436c7067.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eEpidemiology and Control of Hepatitis C Virus (Hcv) Infection in Brunei Darussalam: A Retrospective Cohort Study\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eAs of June 2022, the World Health Organization (WHO) estimated that 58\u0026nbsp;million people worldwide have chronic hepatitis C virus (HCV) infection, with about 1.5\u0026nbsp;million new infections occurring annually.(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) Globally, approximately 290,000 deaths in 2019 were HCV-related, with most deaths attributable to cirrhosis and hepatocellular carcinoma (HCC). In 2019, HCV accounted for 15.3\u0026nbsp;million global disability-adjusted life years (DALYs), with acute hepatitis, cirrhosis and liver cancer contributing 1.7%, 79.5%, and 18.8% to DALYs due to HCV, respectively.(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) Among the WHO Western Pacific Region (WPR) countries, HCV accounted for 26% of all liver cancer deaths as well as 27% of deaths due to liver cirrhosis and other chronic liver disease (CLD) in the WHO WPR (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). In 2019, 25% of the top 20 countries globally for HCV-related deaths are within the WHO WPR.(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eHCV is a ribonucleic acid (RNA) virus from the \u003cem\u003eFlaviviridae\u003c/em\u003e family, has an incubation period of between 0.5 and 6 months, and can cause both acute and chronic infections.(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) The virus can be transmitted through direct percutaneous exposure (such as sharing of contaminated needles among intravenous drug users), vertically from infected mother to child, and sexually (particularly among individuals with multiple sexual partners as well as among men who have sex with men).(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eThe antibody to HCV (anti-HCV) can be detected by enzyme immunoassay, and seroconversion typically occurs around 8\u0026ndash;11 weeks after exposure, whereas HCV RNA is usually detectable earlier, within 1\u0026ndash;2 weeks post exposure.(\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e) For about 30% of HCV infected individuals, their immune system can spontaneously clear the virus within 6 months of infection without any treatment.(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) This group of individuals would test positive for anti-HCV but negative for HCV RNA, and tend to be asymptomatic. The remaining 70% of individuals with HCV would go on to develop chronic infection, indicated by the presence of HCV RNA in their serum. Chronic HCV infection often remain undiagnosed until decades later when symptoms develop from the sequelae of HCV-related complications, such as chronic liver disease, liver cirrhosis and HCC.(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e)\u003c/p\u003e \u003cp\u003ePan-genotypic direct acting-antivirals (DAAs) are the recommended therapy for the treatment of HCV infection.(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) The main aim of treatment is to achieve cure via elimination of the HCV virus, which is defined by the absence of detectable HCV RNA 6 months after treatment completion, also known as achieving sustained virologic response (SVR). SVR attainment has been associated with improvement in all-cause mortality, liver-related mortality, development of HCC as well as other hepatic-related complications.(\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eBrunei Darussalam (population 430,000) is a small country in Southeast Asia with an estimated HCV prevalence of 0.33% in 2022 using Markov model for HCV.(\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e) HCV surveillance data (likely incomplete) is managed by Brunei\u0026rsquo;s Ministry of Health (MOH). However, to date, no studies have described the prevalence and natural history of HCV in the country. Previously published local HCV studies were primarily focussed on treatment response, genotyping or prevalence among a subgroup of patients.(\u003cspan additionalcitationids=\"CR13\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eThis study thus aims to describe the epidemiological and control indicators of HCV cases in Brunei Darussalam. Aggregating national surveillance data with data from the national electronic medical record system, we aim to: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) determine the incidence and prevalence of HCV cases in the country, (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) identify the common possible sources of HCV transmission, (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) identify the determinants of HCV treatment initiation and cure, and lastly, (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) determine the factors associated with HCV-related complications and deaths.\u003c/p\u003e \u003cp\u003eOur study findings could firstly narrow down the long list of countries with no HCV prevalence estimates regionally and globally, a threat recognised by the WHO.(\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e) Secondly and more importantly, it could also inform stakeholders on the scale of this issue, and determine possible ways to address the issue in the national context. Our findings could allow decision makers to estimate the number of people requiring HCV treatment, for HCV resource planning and allocation, and to assess the needs for screening and testing in targeted population groups.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eWe conducted a retrospective cohort study where all diagnosed HCV cases in Brunei Darussalam from January 2013 to December 2022 (10 years) were included. An HCV case is defined as one whose serum sample collected has the presence of anti-HCV. We have included all HCV cases regardless of existing co-morbidities or presence of co-infection with human immunodeficiency virus (HIV) or hepatitis B virus (HBV).\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eCase reporting, testing \u0026amp; investigation\u003c/h2\u003e \u003cp\u003eIn Brunei, HCV screening via detection of the presence of anti-HCV in blood samples is performed for occupational health screening including for healthcare professionals and for pre-employment medical fitness for government employees and foreign workers, for patients with end-stage renal failure (ESRD) undergoing haemodialysis, as well as for donated blood and blood products.(\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e) Additionally, screening for HCV may be conducted in the clinical settings when patients present with suspected liver pathology, and in patients with cancers prior to initiating chemotherapy.\u003c/p\u003e \u003cp\u003eHCV is a notifiable disease under Brunei\u0026rsquo;s Infectious Disease Act since 2003.(\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e) Healthcare professionals from both public and private health facilities in the country are mandated to report all positive anti-HCV cases to the Brunei Centre for Disease Control and Prevention (Brunei CDC), MOH. Once reported, counselling of the cases and active case investigations are conducted by Brunei CDC to identify possible sources of transmission as well as any high-risk close contacts. All HCV cases will be referred to the Hepatology Clinic for further evaluation and management.(\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e) Only HCV cases with detectable HCV RNA (indicating chronic infection) will be offered HCV treatment. Investigations and treatment are free at point-of-care.\u003c/p\u003e \u003cp\u003eFor identified close contacts, the source case will usually provide their details and relay the information for blood HCV screening, after which the results will be traced by Brunei CDC. If negative, no follow-up will be required, whereas if positive for anti-HCV, they will be contacted and counselled as per a confirmed case of HCV. In instances where the close contacts did not attend HCV screening, the source case will be contacted and reminded. However, it is voluntary whether the index cases inform their close contacts and whether their close contacts agree to undergo HCV screening.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eData collection and case identification\u003c/h3\u003e\n\u003cp\u003eTo ensure completeness in case detection, data for this study were obtained from two sources: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) EVYDENCE, and (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) the HCV registry. EVYDENCE is a digital platform that integrates data from several national databases, primarily, the national e-health records system, the Brunei Health Information Management System database (Bru-HIMS), a one-patient-one-record system linking primary and secondary care clinical records, and laboratory and radiological investigations that covers\u0026thinsp;\u0026gt;\u0026thinsp;99% of the population and was first introduced in government health centres and hospitals in 2013.(\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e) The HCV registry is a manual, offline registry maintained by Brunei CDC comprising of all notified HCV cases in Brunei. EVYDENCE includes data from 2013 whereas the HCV registry only comprises HCV cases from 2017 as those prior to 2017 could not be traced.\u003c/p\u003e \u003cp\u003eData collected from EVYDENCE include socio-demographics (age, gender, nationality, ethnicity, district of residence), year of first anti-HCV positive, HCV treatment initiation and completion, HCV RNA level 6 months post treatment, complications related to HCV at diagnosis, as well as deaths related to HCV. For HCV-related complications, further information was collected to identify the type of complications, which include chronic liver disease, liver fibrosis and/or cirrhosis, liver failure, and liver carcinoma. Similarly further data was collected for type of HCV-related deaths, including liver cirrhosis, liver failure, and liver carcinoma. Data collected from the HCV registry include socio-demographics (age, gender, nationality, ethnicity, district of residence), source of HCV acquisition, and year registered as positive HCV case. Incomplete data were manually searched for in Bru-HIMS using the cases\u0026rsquo; unique personal identifier. Duplicate cases from the two data sources were identified and removed.\u003c/p\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eFirst, descriptive statistics was used to report the socio-demographics of all HCV cases included in the study. Using the WHO monitoring and evaluation framework for viral hepatitis as a guide, we reported our outcomes of interest using (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) indicators related to treatment and care, including HCV treatment initiation and completion, and SVR attainment, (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) indicators related to morbidity, including incidence and prevalence, and HCV-related complications at diagnosis, and (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) indicators related to mortality, including HCV-related deaths.(\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eWe calculated the incidence based on the number of new HCV cases during the study period. Annual prevalence was calculated by adding the total number of cases with detectable HCV RNA by the end of the previous year to the number of new cases with detectable HCV RNA in the current year, minus the number of deceased and cured cases from the current year. Paucity of data prior to 2013 means we could not estimate HCV prevalence in 2013. Both incidence and prevalence were reported as rates per 100,000 population.\u003c/p\u003e \u003cp\u003ePatients were considered to have initiated treatment when antiviral therapy for HCV had been prescribed on Bru-HIMS, while patients were considered to have completed treatment if HCV RNA test was performed 6 months after treatment completion to assess for SVR. Patients were considered to have attained SVR if HCV RNA 6 months or more post treatment completion was undetectable. Patients who were found to have HCV-related complications including liver cirrhosis, liver failure and liver carcinoma within one year of their HCV diagnosis were considered to have HCV-related complications at baseline. HCV-related deaths referred to patients who died due to HCV-related causes including liver cirrhosis, liver failure and liver carcinoma.\u003c/p\u003e \u003cp\u003eLogistic regression was used to determine the association between sociodemographic factors and HCV diagnosis year groups with HCV treatment initiation, treatment completion, attainment of SVR, HCV-related complications at baseline as well as deaths due to HCV. All analyses were performed using R ver. 4.2.3.(\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e) We considered p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered as statistically significant.\u003c/p\u003e \u003cp\u003eThe total number of HCV cases were different for the logistic regression analyses in this study as those with missing data were removed by default. To avoid reporting bias, the overall proportions were reported based on the total identified cases.\u003c/p\u003e \u003c/div\u003e"},{"header":"Result","content":"\u003cp\u003eA total of 841 HCV cases were identified from EVYDENCE (n\u0026thinsp;=\u0026thinsp;813) and the HCV registry (n\u0026thinsp;=\u0026thinsp;28), between January 2013 and December 2022 (10 years), and January 2017 to December 2022 (6 years) respectively. Duplicate records (n\u0026thinsp;=\u0026thinsp;23), records with discrepancy in year of diagnosis and date of HCV treatment initiation or diagnosis of complication (n\u0026thinsp;=\u0026thinsp;14), one case with wrong personal identifier (n\u0026thinsp;=\u0026thinsp;1), and patients with no evidence of HCV positive results in Bru-HIMS (n\u0026thinsp;=\u0026thinsp;2) were excluded from the study. The final dataset consisted of 801 HCV cases (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\n\u003ch3\u003eIncidence and prevalence\u003c/h3\u003e\n\u003cp\u003eThe annual incidence rates of HCV cases were highest in 2013 and 2014 at 28.8 and 31.2 per 100,000 population, respectively (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). It then trended downward and remained fairly stable at under 20.0 per 100,000 population, with a slight decline after 2019. On the other hand, the annual prevalence rate was observed to gradually increase from 10.1 per 100,000 population in 2014 to 48.7 per 100,000 population in 2022.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eCharacteristics of HCV cases\u003c/h2\u003e \u003cp\u003eThe mean age of the HCV cases was 43.3 years (95% CI 42.5, 44.2) and men comprised majority of the cases (662, 82.6%) (Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Citizens and permanent residents (691, 86.3%) made up a large proportion of the cases. Malay patients consisted more than half of the HCV cases (530, 66.3%). Most of the HCV cases resided in the Brunei-Muara (359, 44.8%) and Belait (329, 41.1%) districts. The source of HCV acquisition included mother-to-child transmission (1, 0.1%) and sexual intercourse (1, 0.1%), however the source for most the cases were either unknown or not available (799, 99.8%). Among these HCV cases, 457 (57.0%) had detectable HCV RNA while 212 (26.5%) were not tested.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eTreatment initiation and outcomes\u003c/h3\u003e\n\u003cp\u003eAmong patients with positive HCV RNA (n\u0026thinsp;=\u0026thinsp;457), treatment was initiated in 239 (52.3%) cases (table \u003cspan refid=\"MOESM1\" class=\"InternalRef\"\u003eS1\u003c/span\u003e). Cases of age-groups 30\u0026ndash;39 years (adjusted OR (aOR)\u0026thinsp;=\u0026thinsp;2.41 (95% CI 1.17, 5.07)), 40\u0026ndash;44 years (aOR\u0026thinsp;=\u0026thinsp;2.55 (95% CI 1.19, 5.58)) and 50\u0026ndash;54 years (aOR\u0026thinsp;=\u0026thinsp;2.76 (95% CI 1.25, 6.24)) had higher odds of starting HCV treatment when compared with those\u0026thinsp;\u0026lt;\u0026thinsp;30 years old (Table \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Locals had 2.42 times higher odds of starting treatment for HCV compared to foreign residents (aOR\u0026thinsp;=\u0026thinsp;2.42 (95% CI 1.16, 5.36)). HCV cases diagnosed in 2020\u0026ndash;2022 had lower odds of starting treatment (aOR\u0026thinsp;=\u0026thinsp;0.29 (95% CI 0.16, 0.51)) compared with cases diagnosed in 2013\u0026ndash;2014.\u003c/p\u003e \u003cp\u003eAmong cases who initiated treatment (n\u0026thinsp;=\u0026thinsp;239), 166 (69.5%) completed treatment (table \u003cspan refid=\"MOESM1\" class=\"InternalRef\"\u003eS1\u003c/span\u003e). HCV cases diagnosed in 2020\u0026ndash;2022 were found to have lower odds of completing treatment (aOR\u0026thinsp;=\u0026thinsp;0.16 (95% CI 0.05, 0.56)) compared to cases diagnosed in 2013\u0026ndash;2014 (Table \u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAmong those who completed HCV treatment (n\u0026thinsp;=\u0026thinsp;166), 107 (64.5%) achieved SVR (table \u003cspan refid=\"MOESM1\" class=\"InternalRef\"\u003eS1\u003c/span\u003e). Higher odds of SVR attainment were found among HCV cases diagnosed in 2018\u0026ndash;2022 compared to those that were diagnosed earlier in 2013\u0026ndash;2017 (aOR\u0026thinsp;=\u0026thinsp;2.60 (95% CI 1.08, 6.90), Table \u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAmong the HCV cases (n\u0026thinsp;=\u0026thinsp;801), 59 (7.4%) were observed to have HCV-related complications at the time of diagnosis of HCV infection (table \u003cspan refid=\"MOESM1\" class=\"InternalRef\"\u003eS1\u003c/span\u003e). Those aged\u0026thinsp;\u0026ge;\u0026thinsp;50 had 3.32 times higher odds of having complication at baseline compared to those\u0026thinsp;\u0026lt;\u0026thinsp;50 years old (aOR\u0026thinsp;=\u0026thinsp;3.32 (95% CI 1.93, 5.79), Table \u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAmong HCV cases who died (n\u0026thinsp;=\u0026thinsp;129), 47 (36.4%) were found to be related to HCV (table \u003cspan refid=\"MOESM1\" class=\"InternalRef\"\u003eS1\u003c/span\u003e). Among the HCV-related deaths, 12 (25.5%) started treatment, 5 (12.6%) completed treatment, while 2 (4.3%) were cured (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Twenty-one (44.7%) of the HCV-related deaths had HCV-related complications at baseline (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). We did not observe any association between socio-demographic factors and HCV-related deaths (Table \u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCharacteristics of HCV cases from 2013 to 2022, Brunei\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePositive anti-HCV\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c6\" namest=\"c4\"\u003e \u003cp\u003eHCV RNA detected (n\u0026thinsp;=\u0026thinsp;801)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003ePatient characteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTotal (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eYes (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNo (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNot done (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTotal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e801\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e457 (57.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e132 (16.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e212 (26.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMean age (SD)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e43.3 (12.16)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e43.8 (11.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e45.5 (12.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e41.0 (14.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMedian age (IQR)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e44.0 (35\u0026ndash;51)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e44.0 (37\u0026ndash;51)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e47.0 (40\u0026ndash;52)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e41.0 (32\u0026ndash;50)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge range (years)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.0 to 83.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6.0 to 77.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.0 to76.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.0 to 83.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"5\" rowspan=\"6\"\u003e \u003cp\u003e\u003cb\u003eAge group (years)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e0\u0026ndash;29\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e98 (12.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e49 (10.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e12 (9.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e37 (17.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e30\u0026ndash;39\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e185 (23.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e107 (23.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e18 (13.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e60 (28.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e40\u0026ndash;44\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e134 (16.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e79 (17.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e23 (17.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e32 (15.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e45\u0026ndash;49\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e143 (17.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e84 (18.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e31 (23.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e28 (13.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e50\u0026ndash;59\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e188 (23.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e112 (24.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e37 (28.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e39 (18.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e60+\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e53 (6.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e26 (5.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e11 (8.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e16 (7.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eGender\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eMale\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e662 (82.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e369 (80.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e110 (83.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e183 (86.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eFemale\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e139 (17.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e88 (19.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e22 (16.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e29 (13.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eNationality\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eLocal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e691 (86.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e418 (91.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e122 (92.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e151 (71.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eForeign\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e110 (13.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e39 (8.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e10 (7.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e61 (28.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003cb\u003eEthnicity\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eMalay\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e530 (66.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e312 (68.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e96 (72.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e122 (57.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eChinese\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e54 (6.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e29 (6.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8 (6.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e17 (8.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eOthers\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e78 (9.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e33 (7.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e17 (12.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e28 (13.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eUnknown\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e139 (17.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e83 (18.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e11 (8.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e45 (21.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003cb\u003eDistrict of residence\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eBrunei-Muara\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e359 (44.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e195 (42.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e62 (47.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e102 (48.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eBelait\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e329 (41.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e198 (43.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e49 (37.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e82 (38.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eTemburong\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (1.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 (1.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3 (2.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e3 (1.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eTutong\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e102 (12.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e59 (12.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e18 (13.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e25 (11.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003cb\u003eYear of diagnosis\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e2013\u0026ndash;2014\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e243 (30.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e143 (31.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e47 (35.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e53 (25.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e2015\u0026ndash;2016\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e177 (22.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e86 (18.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e36 (34.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e45 (21.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e2017\u0026ndash;2019\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e211 (26.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e128 (28.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e32 (24.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e51 (24.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e2020\u0026ndash;2022\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e170 (21.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e100 (21.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7 (5.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e63 (29.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eHCV, hepatitis C virus; RNA, ribonucleic acid.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eFactors associated with HCV treatment initiation among HCV cases with detectable HCV RNA, Brunei\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c2\" namest=\"c1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c6\" namest=\"c3\"\u003e \u003cp\u003eHCV treatment initiated\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes (n\u0026thinsp;=\u0026thinsp;239) n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNo (n\u0026thinsp;=\u0026thinsp;218) n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCrude OR (95% CI)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAdjusted OR (95% CI)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"5\" rowspan=\"6\"\u003e \u003cp\u003e\u003cb\u003eAge group (years)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e0\u0026ndash;29\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18 (7.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e31 (14.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e30\u0026ndash;39\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e60 (25.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e47 (21.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e2.20 (1.11, 4.47)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e2.41 (1.17, 5.07)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e40\u0026ndash;44\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e48 (20.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e31 (14.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e2.67 (1.29, 5.65)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e2.55 (1.19, 5.58)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e45\u0026ndash;49\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e49 (20.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e35 (16.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e2.41 (1.18, 5.05)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.11 (1.00, 4.53)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e50\u0026ndash;54\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e38 (15.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e28(12.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e2.34 (1.10, 5.06)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e2.76 (1.25, 6.24)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e\u0026ge;\u0026thinsp;55\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26 (10.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e46 (21.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.97 (0.46, 2.08)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.10 (0.50, 2.45)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eGender\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eMale\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e201 (84.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e168 (77.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.57 (0.99, 2.53)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.46 (0.88, 2.45)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eFemale\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e38 (15.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e50 (22.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eNationality\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eLocal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e228 (95.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e190 (87.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e3.05 (1.52, 6.56)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e2.42 (1.16, 5.36)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eForeign\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (4.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e28 (12.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003cb\u003eYear of diagnosis\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e2013\u0026ndash;2014\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e88 (36.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e55 (25.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e2015\u0026ndash;2016\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e55 (23.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e31 (14.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.11 (0.64, 1.94)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.13 (0.63, 2.03)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e2017\u0026ndash;2019\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e65 (27.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e63 (28.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.64 (0.40, 1.04)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.65 (0.39, 1.08)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e2020\u0026ndash;2022\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e31 (13.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e69 (31.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.28 (0.16, 0.48)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.29 (0.16, 0.51)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eHCV, hepatitis C virus; RNA, ribonucleic acid.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eFactors associated with HCV treatment completion among cases who initiated HCV treatment (n\u0026thinsp;=\u0026thinsp;209 out of 239 (87.4%))\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c2\" namest=\"c1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c6\" namest=\"c3\"\u003e \u003cp\u003eHCV treatment completed\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes (n\u0026thinsp;=\u0026thinsp;166) n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNo (n\u0026thinsp;=\u0026thinsp;43) n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCrude OR (95% CI)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAdjusted OR (95% CI)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e\u003cb\u003eAge group (years)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e0\u0026ndash;29\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (6.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (9.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e30\u0026ndash;39\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e43 (25.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10 (23.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.56 (0.37, 5.73)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.79 (0.40, 7.00)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e40\u0026ndash;44\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34 (20.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7 (16.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.77 (0.40, 7.08)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.88 (0.41, 7.95)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e45\u0026ndash;49\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39 (23.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6 (14.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.36 (0.53, 9.86)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.27 (0.49, 9.76)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e\u0026ge;\u0026thinsp;50\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39 (23.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16 (37.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.89 (0.23, 3.87)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.06 (0.25, 3.85)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eGender\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eMale\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e142 (85.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e36 (83.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.15 (0.22, 3.04)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.09 (0.39, 2.80)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eFemale\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24 (14.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7 (16.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eNationality\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eLocal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e161 (97.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e40 (93.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.42 (0.48, 10.26)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.38 (0.43, 11.13)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eForeign\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (3.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (7.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003cb\u003eYear of diagnosis\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e2013\u0026ndash;2014\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e72 (43.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13 (30.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e2015\u0026ndash;2016\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e43 (25.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10 (23.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.78 (0.31, 1.96)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.81 (0.32, 2.11)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e2017\u0026ndash;2019\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e45 (27.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12 (27.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.68 (0.28, 1.63)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.72 (0.30, 1.78)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e2020\u0026ndash;2022\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (3.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8 (18.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.14 (0.04, 0.45)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.16 (0.05, 0.56)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eHCV, hepatitis C virus.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eFactors associated with SVR attainment among patients who completed HCV treatment\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c2\" namest=\"c1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c6\" namest=\"c3\"\u003e \u003cp\u003eSVR achieved\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes (n\u0026thinsp;=\u0026thinsp;107) n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNo (n\u0026thinsp;=\u0026thinsp;59) n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCrude OR (95% CI)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAdjusted OR (95% CI)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e\u003cb\u003eAge group (years)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e0\u0026ndash;29\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (5.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 (8.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e30\u0026ndash;39\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28 (26.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15 (25.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.56 (0.39, 6.03)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.16 (0.28, 4.62)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e40\u0026ndash;44\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27 (25.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7 (11.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.21 (0.74, 14.12)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.35 (0.52, 10.65)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e45\u0026ndash;49\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26 (24.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13 (22.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.67 (0.41, 6.59)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.42 (0.35, 5.69)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e\u0026ge;\u0026thinsp;50\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20 (18.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19 (32.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.88 (0.22, 3.39)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.60 (0.14, 2.42)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eGender\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eMale\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e94 (87.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e48 (81.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.66 (0.68, 3.98)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.61 (0.62, 4.14)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eFemale\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13 (12.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11 (18.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eNationality\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eLocal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e103 (96.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e58 (98.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.44 (0.02, 3.09)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.41 (0.02, 3.46)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eForeign\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (3.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (1.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eYear of diagnosis\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e2013\u0026ndash;2017\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e79 (73.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e51 (86.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e2018\u0026ndash;2022\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28 (26.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8 (13.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.26 (0.99, 5.66)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e2.60 (1.08, 6.90)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eHCV, hepatitis C virus; RNA, ribonucleic acid.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eFactors associated with presence of HCV-complications at diagnosis among HCV cases and HCV-related deaths among HCV cases who died, Brunei\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"10\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c2\" namest=\"c1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c6\" namest=\"c3\"\u003e \u003cp\u003eHad HCV-related complications at diagnosis (n\u0026thinsp;=\u0026thinsp;801)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c10\" namest=\"c7\"\u003e \u003cp\u003eDied due to HCV (n\u0026thinsp;=\u0026thinsp;129)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes (n\u0026thinsp;=\u0026thinsp;59) n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNo (n\u0026thinsp;=\u0026thinsp;742) n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCrude OR (95% CI)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAdjusted OR (95% CI)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eYes (n\u0026thinsp;=\u0026thinsp;47) n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNo (n\u0026thinsp;=\u0026thinsp;82) n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eCrude OR (95% CI)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eAdjusted OR (95% CI)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eAge group (years)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;50\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25 (42.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e535 (72.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e17 (36.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e31 (37.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e\u0026ge;\u0026thinsp;50\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34 (57.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e207 (27.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e3.51 (2.05, 6.09)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e3.32 (1.93, 5.79)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e30 (63.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e51 (62.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e1.07 (0.51, 2.28)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.96 (0.44, 2.12)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eGender\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eMale\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e44 (74.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e618 (83.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.59 (0.32, 1.12)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.72 (0.39, 1.39)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e30 (63.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e59 (72.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.69 (0.32, 1.49)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.66 (0.29, 1.48)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eFemale\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15 (25.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e124 (16.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e17 (36.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e23 (28.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eNationality\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eLocal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e55 (93.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e636 (85.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.29 (0.92, 7.68)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.06 (0.81, 6.98)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e45 (95.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e80 (97.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.56 (0.07, 4.82)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.51 (0.06, 4.46)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eForeign\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (6.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e106 (14.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2 (4.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e2 (2.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eYear of diagnosis\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e2013\u0026ndash;2017\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34 (57.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e450 (60.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e35 (74.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e63 (76.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e2018\u0026ndash;2022\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25 (42.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e292 (39.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.13 (0.66, 1.93)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.12 (0.64, 1.92)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e12 (25.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e19 (23.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e1.14 (0.49, 2.59)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e1.12 (0.47, 2.60)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eHCV, hepatitis C virus; RNA, ribonucleic acid.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eOur study findings revealed several key points highlighting the need for better control of HCV cases in Brunei Darussalam. First is the increasing prevalence, indicating that the number of cases living with chronic HCV infection in the country are increasing. Second is the significant proportion of HCV cases who were not tested for HCV RNA, the step needed to initiate treatment in the first place. Finally, is the increased mortality among those with baseline HCV-related complications.\u003c/p\u003e \u003cp\u003eThe increasing prevalence observed could be due to the downward trend in both HCV treatment initiation and completion during the study period. In Brunei, pegylated interferon-alpha was the main treatment of choice for HCV until 2018 when DAA was first introduced. However, both therapies were under named-patient basis (NPB) which required authorization for procurement and dispensing, and the administrative procedure could be time-consuming. Furthermore, the availability of these medications from pharmacy was not consistent due to internal procurement processes. The inadvertent delays and disruption in treatment could have resulted in negative perception of healthcare providers by patients leading to distrust and subsequent default and loss to follow-up.(\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e) This suggests the need to explore how medication supply can be improved and how clinical management of HCV cases can be enhanced to ensure timely follow-up and medication adherence. Although DAA was removed from the NPB list since 2020 making it more accessible, this coincided with the COVID-19 pandemic which affected routine healthcare services including patient follow-up and could have further amplified the issues with HCV treatment initiation and completion during this time.(\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eWe also found that more than a quarter of new HCV cases were not tested for HCV RNA, and that more than three-quarters of them were locals. This could be due to several reasons. First, the positive anti-HCV results could be missed by the attending physicians. Second, the new HCV cases were not notified to Brunei CDC hence no consultation and onward referral to the Hepatology Clinic for HCV RNA testing was arranged. Third, patients failed to attend their appointments at the Hepatology Clinic. This may indicate that the HCV prevalence could be higher that what we have reported due to these HCV cases with unknown HCV RNA status. Notably, HCV treatment for locals is available for free, hence monetary cost is not a barrier to testing. Thus, this missed opportunity to test for HCV RNA among new HCV cases is concerning and warrants actions from both public health authorities and clinicians to ensure more stringent protocols are in place for follow-up and further testing of new HCV cases.\u003c/p\u003e \u003cp\u003ePrevious studies reported HCV treatment initiation rates among HCV RNA-positive patients ranging from 20% to over 60%, while we reported a rate of around 50%.(\u003cspan additionalcitationids=\"CR25\" citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e) This can be attributed to access to care, affordability of HCV treatment, whether treatment was received at primary care or gastroenterology clinic, and changes in HCV treatment policies. While our study did not evaluate these factors, we found that HCV patients aged\u0026thinsp;\u0026lt;\u0026thinsp;55 generally had higher odds of starting treatment. This could be due to the younger age groups\u0026rsquo; eligibility as treatment candidate as they would have less co-morbidities and concerns of treatment side effects when compared to elderly patients.(\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e) Around 30% of our study patients were aged 50 years and above, and this group had higher odds of having HCV-related complications at baseline, which could have hindered them from commencing treatment.\u003c/p\u003e \u003cp\u003eOur study did not find any significant association between HCV-related deaths and sociodemographic factors. Other studies have previously identified clinical factors such as failure to achieve SVR, presence of severe liver disease at baseline, and HCV viraemia (detectable HCV RNA) to be significantly associated with mortality due to HCV.(\u003cspan additionalcitationids=\"CR28\" citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e) Although these were not included in our analysis, we found that nearly 50% of our cases who died due to HCV had baseline HCV-related complications, suggesting a need to promote early screening and adequate follow-up for new HCV cases with HCV-related complications.\u003c/p\u003e \u003cp\u003eOne major strength of our study is the utilization of a national electronic health records system for case identification, in addition to the offline HCV registry. This allowed for a more comprehensive capture of all anti-HCV and HCV RNA positive patients in Brunei to provide better estimates of the population incidence and prevalence of HCV cases, respectively. Second, this study revealed the limitations of our offline HCV registry as seen in the discrepancy in the number of cases captured from EVYDENCE compared to the HCV registry and exposed the shortfall in mandatory reporting of HCV cases in the country. However, this provides a strong rationale to migrate to an online-based registry in order to have a more complete HCV case detection.\u003c/p\u003e \u003cp\u003eThis study has several limitations. First, the prevalence cases in 2013 could not be determined while the incidence cases could have been overestimated. During the adoption of Bru-HIMS in 2013, all new and old HCV cases who had a positive anti-HCV test result in that year were captured as new. Because we could not obtain surveillance data prior to 2013, we were unable to differentiate between the new and old cases in that year. Second, data extraction using ICD-10 codes relied on clinicians\u0026rsquo; input of the codes as well as the correct ICD-10 codes being entered in order for the intended information, such as types of complication, to be extracted. This may result in underestimation of the HCV complications at baseline if ICD-10 were incorrectly or not recorded. Third, only deaths recorded on Bru-HIMS were included in this study. Deaths from the community were not captured as these were not reflected in their clinical records, therefore the death figures obtained from this study may be underreported. Fourth, although HCV is known to be prevalent among key population groups such as people who inject drugs (PWID) and prisoners, we could not obtain data on the source of HCV acquisition and incarceration history among the HCV cases due to limitation in data extraction.(\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e) Lastly, the present study did not include HCV genotypes, types of treatment, and presence of other co-morbidities or co-infection with HIV or HBV in the analyses which may better reflect the association with the outcomes of interest.\u003c/p\u003e \u003cp\u003eHere we identified several avenues for future research. First, improvement in data extraction to quantify source of HCV acquisition and access to information on whether cases are currently incarcerated would allow for future analyses of at-risk population groups and assess whether tailored HCV management is needed for these groups. Second, further investigation is needed to determine why new HCV cases could be missed for HCV RNA testing. Third, more in-depth evaluation is warranted to explore other possible factors that may have contributed to the observed downward trends in treatment completion and initiation. Determining the reasons behind these are crucial to help identify potential barriers in HCV management so that more appropriate and applicable solutions can be implemented.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eIn conclusion, our study highlights a rising HCV prevalence likely due to decreasing trends in treatment initiation and completion which underscores gaps in our local HCV management, suggesting the need to review follow-up protocols as well as medication procurement processes and supply chain. More than a quarter of new cases were not tested for HCV RNA, which may indicate a higher HCV prevalence than what we have reported and calls for actions to improve existing guidelines for HCV RNA testing among new HCV cases. We found that nearly 50% of patients who died from HCV had complications at baseline, emphasizing the need for early screening and thorough follow-up. We recommend more comprehensive data collection and analyses in future studies that would better capture at-risk population groups to formulate targeted strategies and interventions. In-depth exploration of challenges to HCV testing and treatment is also crucial to address potential barriers and develop effective solutions.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eanti-HCV\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAntibodies against hepatitis C virus\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eBrunei CDC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eBrunei Centre for Disease Control and Prevention\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eBru-HIMS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eBrunei Health Information Management System database\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCLD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eChronic liver disease\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eDAA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eDirect acting-antivirals\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eDALYs\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eDisability-adjusted life years\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eESRD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eEnd-stage renal failure\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eHBV\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eHepatitis B virus\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eHCV\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eHepatitis C virus\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eHCC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eHepatocellular carcinoma\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eHIV\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eHuman immunodeficiency virus\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMOH\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMinistry of Health\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eNPB\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eNamed-patient basis\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePWID\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePeople who inject drugs\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eRNA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eRibonucleic acid\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSVR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSustained virologic response\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eWPR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eWestern Pacific Region\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eWHO\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eWorld Health Organization\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":" \u003cp\u003e \u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e \u003cp\u003eThis study involves human participants and was approved by Ethical committee name: Joint Research Ethics Committee of PAPRSB Institute of Health Science (IHSREC) and Medical and Health Research Ethics (MHREC), UBD Reference no: UBD/PAPRSBIHSREC/2023/31. Informed consent was waived as study involves the use of retrospectively collected patient data recorded by the Ministry of Health for the purposes of investigations related to HCV (in accordance with the Infectious Disease Act).\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent for publication\u003c/strong\u003e \u003cp\u003eNot applicable.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eCompeting interests\u003c/h2\u003e \u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eNot applicable.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eKSK and JW conceived the study. KSK analysed the data and drafted the manuscript. KSK and LC interpreted the results. All authors read, revised and approved the manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eThe authors would like to thank Lee Thian Hui, Shannon Newn, Liwani Nursyafiqah Bahari and Lim Sheau Ling from EVYD Technology Limited for assisting with data extraction from EVYDENCE, as well as Brunei CDC for providing data from the HCV registry. The authors are also grateful to Dr Chong Vui Heng and Dr Kyaw Thu for their technical expertise in this manuscript.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eData used during this in are available from the corresponding author upon reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWorld Health Organization, Hepatitis C. 2024. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.who.int/news-room/fact-sheets/detail/hepatitis-c\u003c/span\u003e\u003cspan address=\"https://www.who.int/news-room/fact-sheets/detail/hepatitis-c\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 17 Jul 2024.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eInstitute for Health Metrics and Evaluation. Total burden related to hepatitis C. Washington: Institute for Health Metrics and Evaluation. 2022. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.healthdata.org/results/gbd_summaries/2019/total-burden-related-to-hepatitis-c-level-3-cause 1027.pdf\u003c/span\u003e\u003cspan address=\"https://www.healthdata.org/results/gbd_summaries/2019/total-burden-related-to-hepatitis-c-level-3-cause 1027.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 17 Oct 2022.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Health Organization Western Pacific Region. Regional hepatitis data. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.who.int/westernpacific/health-topics/hepatitis/regional-hepatitis-data\u003c/span\u003e\u003cspan address=\"https://www.who.int/westernpacific/health-topics/hepatitis/regional-hepatitis-data\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 18 Oct 2022.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCoalition for Global Hepatitis Elimination. Interim report: progress towards HBV and HCV elimination in the Western Pacific Region. Georgia: Coalition for Global Hepatitis Elimination. 2021. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.globalhep.org/interim-report-progress-towards-hbv-and-hcv-elimination-western-pacific-region\u003c/span\u003e\u003cspan address=\"https://www.globalhep.org/interim-report-progress-towards-hbv-and-hcv-elimination-western-pacific-region\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 10 Jan 2023.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlter MJ. Epidemiology of hepatitis C virus infection. World J Gastroenterol. 2007;13(17):2436\u0026ndash;41.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCenters for Disease Control and Prevention. Hepatitis C questions and answers for health professionals. US: Centers for Disease Control and Prevention. 2020. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.cdc.gov/hepatitis/hcv/hcvfaq.htm\u003c/span\u003e\u003cspan address=\"https://www.cdc.gov/hepatitis/hcv/hcvfaq.htm\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 8 Dec 2022.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChen SL, Morgan TR. The natural history of hepatitis C virus (HCV) infection. Int J Med Sci. 2006;3(2):47\u0026ndash;52.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLaraque F, Varma JK. A public health approach to hepatitis C in an urban setting. Am J Public Health. 2017;107(6):922\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNg V, Saab S. Effects of a sustained virologic response on outcomes of patients with chronic hepatitis C. Clin Gastroenterol Hepatol. 2011;9(11):923\u0026ndash;30.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVeldt BJ, Heathcote EJ, Wedemeyer H, Reichen J, Hofmann WP, Zeuzem S, et al. Sustained virologic response and clinical outcomes in patients with chronic hepatitis C and advanced fibrosis. Ann Intern Med. 2007;147(10):677\u0026ndash;84.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCoalition for Global Hepatitis Elimination. Brunei Darussalam. Georgia: Coalition for Global Hepatitis Elimination. 2023. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.globalhep.org/data-profiles/countries/brunei-darussalam\u003c/span\u003e\u003cspan address=\"https://www.globalhep.org/data-profiles/countries/brunei-darussalam\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 24 Sep 2024.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChong VH, Zinna HS. Hepatitis C virus infection and haemodialysis: experience of a district general hospital in Brunei Darussalam. Singap Med J. 2008;49(11):916\u0026ndash;20.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChong VH, Jamaludin AZF, Alexander MJ, Jacob AP, Jalihal A. Chronic hepatitis C treatment response to combination therapy: experience of RIPAS Hospital. Brunei Int Med J. 2010;6(2):92\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChong VH, Jamaludin AZF, Jalihal A. Hepatitis C in Brunei Darussalam: a genotypic study. J Gastroenterol Hepatol. 2006;21:A19.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Health Organization. Global health sector strategies on, respectively, HIV, viral hepatitis and sexually transmitted infections for the period 2022\u0026ndash;2030. Geneva: World Health Organization. 2022. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://apps.who.int/iris/handle/10665/362227\u003c/span\u003e\u003cspan address=\"https://apps.who.int/iris/handle/10665/362227\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 17 Oct 2022.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIversen J, Wand H, Chan PL, Le LV, Maher L. Systematic review of hepatitis C virus prevalence in the WHO Western Pacific Region. Viruses. 2022;14(7):1548.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLaws of Brunei. Chapter 204 Infectious Diseases. 2010. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.agc.gov.bn/AGCImages/LAWS/ACT_PDF/\u003c/span\u003e\u003cspan address=\"https://www.agc.gov.bn/AGCImages/LAWS/ACT_PDF/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 3 Jan 2023.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKoh KS, Lim HS, Lim J, Wei Y, Minn PW, Wong J. Development and implementation of a national mobile health application: a case study from Brunei. J Glob Health. 2022;12:03083.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMinistry of Health Brunei. Bru-HIMS. Brunei: Ministry of Health. 2020. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.moh.gov.bn/SitePages/Bru-HIMS.aspx\u003c/span\u003e\u003cspan address=\"https://www.moh.gov.bn/SitePages/Bru-HIMS.aspx\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 10 Jan 2023.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Health Organization. WHO monitoring and evaluation for viral hepatitis B and C: recommended indicators and framework. Geneva: World Health Organization. 2016. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://apps.who.int/iris/handle/10665/204790\u003c/span\u003e\u003cspan address=\"https://apps.who.int/iris/handle/10665/204790\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 21 Oct 2023.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eR Core Team. (2022). R: a language and environment for statistical computing. Austria: R Foundation for Statistical Computing. 2022. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.r-project.org/\u003c/span\u003e\u003cspan address=\"https://www.r-project.org/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 10 Jan 2023.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eden Boogert EM, Veldhuijzen IK, Generaal E, Prins M, Sonneveld MJ, van der Meer AJ, et al. Substantial impact of the COVID-19 pandemic on the reported number of diagnosed chronic hepatitis C virus infections in the Netherlands, 2019\u0026ndash;2021. BMC Public Health. 2023;23(1):1244.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKaufman HW, Bull-Otterson L, Meyer WA, Huang X, Doshani M, Thompson WW, et al. Decreases in hepatitis C testing and treatment during the COVID-19 pandemic. Am J Prev Med. 2021;61(3):369\u0026ndash;76.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNguyen VH, Kam L, Yeo YH, Huang DQ, Henry L, Cheung R, et al. Characteristics and treatment rate of patients with hepatitis C virus infection in the direct-acting antiviral era and during the COVID-19 pandemic in the United States. JAMA Netw Open. 2022;5(12):e2245424.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhang C, Lu J, Zhang Y, He P, Xia J, Huang M. Prevalence, diagnosis, treatment, and associated factors of hepatitis C in the United States from 1999 to 2018: a population-based cross-sectional study. Liver Res. 2022;6(4):284\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKapadia SN, Zhang H, Gonzalez CJ, Sen B, Franco R, Hutchings K, et al. Hepatitis C treatment initiation among US medicaid enrollees. JAMA Netw Open. 2023;6(8):e2327326.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePiselli P, Serraino D, Fusco M, Girardi E, Pirozzi A, Toffolutti F, et al. Hepatitis C virus infection and risk of liver-related and non-liver-related deaths: a population-based cohort study in Naples, southern Italy. BMC Infect Dis. 2021;21:667.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSingal AG, Volk ML, Jensen D, et al. A sustained viral response is associated with reduced liver-related morbidity and mortality in patients with hepatitis C virus. Clin Gastroenterol Hepatol. 2010;8(3):280\u0026ndash;8. 288.e1.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUto H, Stuver SO, Hayashi K, Kumagai K, Sasaki F, Kanmura S, et al. Increased rate of death related to presence of viremia among hepatitis C virus antibody-positive subjects in a community-based cohort study. Hepatology. 2009;50(2):393\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJiang N, Bruneau J, Makarenko I, Minoyan N, Zang G, H\u0026oslash;j SB, et al. HCV treatment initiation in the era of universal direct acting antiviral coverage \u0026ndash; improvements in access and persistent barriers. Int J Drug Policy. 2023;113:103954.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNelson P, Mathers B, Cowie B, Hagan H, Jarlais DD, Horyniak D, et al. The epidemiology of viral hepatitis among people who inject drugs: results of global systematic reviews. Lancet. 2011;378(9791):571\u0026ndash;83.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Hepatitis C virus, epidemiology, treatment, mortality, Brunei","lastPublishedDoi":"10.21203/rs.3.rs-5149746/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5149746/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eWe describe the epidemiology of hepatitis C virus (HCV) cases in Brunei Darussalam, and evaluated factors associated with HCV treatment initiation, completion, achieving sustained virologic response (SVR), baseline HCV-related complications, and HCV-related deaths.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA retrospective cohort study was conducted from January 2013 to December 2022 using data derived from EVYDENCE and the HCV registry to identify all diagnosed HCV cases in Brunei. Multivariable logistic regression was used to determine the associated factors.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eWhile incidence rates remained stable over a decade at below 20.0 per 100,000 population, we observed rising prevalence rates from 10.1 to 48.7 per 100,00 population in 2014 and 2022, respectively. Among 801 anti-HCV positive cases identified, 57% (n\u0026thinsp;=\u0026thinsp;457) had detectable HCV RNA, 16.5% (n\u0026thinsp;=\u0026thinsp;132) were HCV RNA negative, while 26.5% (n\u0026thinsp;=\u0026thinsp;212) were not tested for HCV RNA. Treatment was initiated in 52.3% (n\u0026thinsp;=\u0026thinsp;239) of HCV RNA positive cases, with higher odds among those aged 30\u0026ndash;54 years [30\u0026ndash;39 years (adjusted OR (aOR)\u0026thinsp;=\u0026thinsp;2.41 (95% CI 1.17, 5.07)), 40\u0026ndash;44 years (aOR\u0026thinsp;=\u0026thinsp;2.55 (95% CI 1.19, 5.58)), 50\u0026ndash;54 years (aOR\u0026thinsp;=\u0026thinsp;2.76 (95% CI 1.25, 6.24))] and locals (aOR\u0026thinsp;=\u0026thinsp;2.42 (95% CI 1.16, 5.36)). Cases diagnosed in 2020\u0026ndash;2022 had lower odds of starting (aOR\u0026thinsp;=\u0026thinsp;0.29 (95% CI 0.16, 0.51)) and completing (aOR\u0026thinsp;=\u0026thinsp;0.16 (95% CI 0.05, 0.56)) treatment. Among 239 cases who initiated treatment, 69.5% (n\u0026thinsp;=\u0026thinsp;166) completed treatment. 64.5% (n\u0026thinsp;=\u0026thinsp;107) of these achieved SVR, with higher odds in cases diagnosed in 2018\u0026ndash;2022 (aOR\u0026thinsp;=\u0026thinsp;2.60 (95% CI 1.08, 6.90). 7.4% (n\u0026thinsp;=\u0026thinsp;59) had HCV-related complications at baseline, with higher odds in those aged\u0026thinsp;\u0026ge;\u0026thinsp;50 (aOR\u0026thinsp;=\u0026thinsp;3.32 (95% CI 1.93, 5.79). Among 129 deaths, 36.4% (n\u0026thinsp;=\u0026thinsp;47) were HCV-related, of which 44.7% (n\u0026thinsp;=\u0026thinsp;21) had HCV-related complications at baseline.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eWe observed rising HCV prevalence in Brunei, likely due to the decline in treatment initiation and completion. This reveals gaps in our HCV management and calls for actions to strengthen public health and clinical care strategies. Nearly half of the HCV deaths had baseline HCV-complications, highlighting the need for early screening and follow-up. Future studies should determine at-risk populations and explore barriers to HCV testing and care, to adequately address these issues and provide effective solutions.\u003c/p\u003e","manuscriptTitle":"Epidemiology and Control of Hepatitis C Virus (Hcv) Infection in Brunei Darussalam: A Retrospective Cohort Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-01-15 10:48:53","doi":"10.21203/rs.3.rs-5149746/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"decffdbb-bb44-4bba-a84d-c70669a6ecfc","owner":[],"postedDate":"January 15th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-09-29T06:23:23+00:00","versionOfRecord":[],"versionCreatedAt":"2025-01-15 10:48:53","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5149746","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5149746","identity":"rs-5149746","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}