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SARS-CoV-2 massive testing: A window of
opportunity to catch up with HCV elimination
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Download the PDF here
Download the PDF here
October 08, 2020
Therefore, in accordance with Wingrove et al.,9 we consider that i) HCV and HBV status should be assessed in every patient undergoing SARS-CoV-2 testing; 2) HCV elimination programs should be restarted as soon as possible, especially in vulnerable populations, where the impact of the interruption of HCV elimination programs will be shocking. This way we will avoid the direct consequences of the paralysis of HCV elimination programs and, simultaneously, we send an optimistic message to people: public health programs can be maintained, even in these uncertain times.
In fact, the first wave of the COVID-19 pandemic overwhelmed healthcare systems around the world, with far-reaching consequences.4 Along this line, Blach et al.5 modeled the devastating consequences of delaying HCV elimination programs. This delay will be reflected in an increase of HCV-related mortality, both as consequence of cirrhosis complications and hepatocellular carcinoma (HCC) development. A single-year delay may result in an excess of 70,000 liver-related deaths and 44,000 excess HCC diagnoses.
The COVID-19 crisis has forced the diversion of the majority of healthcare resources towards the care of infected patients, impacting the management of those with other conditions. A clear example is patients infected with HCV.6 Unfortunately, the closure of harm reduction centers, cancellation of elimination programs and medical consultations, as well as reduced access to healthcare centers, is decreasing the rate of HCV diagnoses. In fact, in a recent survey evaluating the impact of COVID-19 on viral hepatitis, up to 64% of participants reported it being impossible to access viral testing, with the closure of testing facilities being the main cause in the United States.7 Consequently, this diagnostic delay will be translated into a delay in treatment initiation, whose consequences have been predicted by Blach et al.,5 and have been seen in the past.8
Patients that must already attend healthcare facilities for SARS-CoV-2 testing, could also be screened for HCV and HBV, in a single visit. Integrating HCV detection programs9 into SARS-CoV-2 testing will likely have a very small economic cost, with the potential to be hugely profitable down the line. Since COVID-19 may induce liver damage, albeit rarely, and the current viral armamentarium includes multiple potentially hepatotoxic drugs, HBV and HCV screening could be important in the management of patients with suspected SARS-CoV-2 infection. Furthermore, SARS-CoV-2 and hepatitis tests could be easily performed at the same time by means of point-of-care techniques, using saliva assays or dried blood spots, preventing further redundant analyses. Thus, establishing integrated diagnostic circuits may prevent unnecessary repeat sampling.
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Detecting HCV infection by means of mass population SARS-CoV-2 screening: a pilot experience in Northern Italy
rapid HCV testing in the context of SARS-CoV-2 screening programmes is a further means of achieving the WHO’s 2030 HCV elimination target
January 12, 2021 Lancet Gastro, Hep
To the Editor
We read with interest the paper by Crespo et al., who suggested that mass severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) testing offers a unique opportunity to screen for viral hepatitis, particularly hepatitis C virus (HCV) infection [1].
As the COVID-19 pandemic has overwhelmed entire national healthcare systems and severely strained their ability to manage patients with chronic diseases, such as those with chronic viral hepatitis [2], we agree that access to screening programmes and subsequent linkage to care would possibly turn the challenges of the pandemic in new opportunities.
Mass serological SARS-CoV-2 screening has been capable of revealing the spread of the disease in Europe [3]. After our first successful attempt at using rapid immunochromatographic testing (RICT) to screen for SARS-CoV-2 antibodies in Castiglione d’Adda, an area of early viral circulation in Northern Italy [4], we not only extended the programme to five other towns in Lombardy, but also included rapid HCV screening in three: San Pellegrino Terme (4,840 inhabitants) and Suisio (3,828 inhabitants) in the province of Bergamo north-east of Milan, and Sordio (3,429 inhabitants) in the province of Lodi south-east of Milan. With the full support and collaboration of the local authorities, all of the inhabitants of these three towns were invited to undergo voluntary screening in suitably adapted, publicly owned buildings (schools and sports centres) at the beginning of August (Suisio), the end of September (Sordio), or between the end of October and mid-November (San Pellegrino Terme). After giving their informed consent, they underwent RICT for SARS-CoV-2 antibodies (PrimaLab COVID-19 IgG/IgM Rapid Test, Balerna, Switzerland in Suisio; Technogenetics Rapid Test COVID-19 IgM/IgG, Milan, Italy in Sordio and San Pellegrino Terme), and those aged >50 years (or younger if they explicitly requested it) underwent RICT for HCV antibodies (Meridian Bioscience OraQuick HCV-Rapid Antibody Test Cincinnati, OH, USA). They also completed a questionnaire to ascertain whether they were aware of a previous HCV infection.
A total of 5,152 subjects (42.6% of the inhabitants of the three towns together) underwent SARS-CoV-2 screening, and almost half of these (n=2,505, 48.6%) also underwent HCV screening, including 79.3% of those aged >50 years. Table 1 shows the results of the HCV tests: 72 subjects (2.9%, 95% confidence interval [CI] 2.3-3.6%) were positive for HCV antibodies (ranging from 2.1% [95% CI 1.1-3.6%] in Sordio to 3.4% [95% CI 2.4-4.6%] in San Pellegrino Terme). Fewer than half (46.1%) of these were aware of their serostatus.
On the basis of historical data, the overall seroprevalence of HCV in Italy is about 2% (1.6-7.3%), with the vast majority of infections reported in subjects aged >60 years, and an increasing gradient from northern to southern Italy [5]. The 2.9% seroprevalence observed in our study is similar to the northern Italian general population estimates made about 20 years ago (3.3%) [6].
The fact that 53.9% of the HCV-positive subjects were unaware of their serostatus may seem high but it is lower than the estimated 66% made by a European study in 2015 [7].
The limitations of this study include the absence of simultaneous HCV-RNA testing, although all of the positive subjects were counselled and given prescriptions for diagnostic investigations (including HCV-RNA testing) and subsequent linkage to care. Unfortunately, due to the limited time available, the questionnaire ascertained only whether participants were aware of a previous HCV infection, while no information regarding previous HCV treatments was recorded among those tested positive. Secondly, the reported sensitivity and accuracy of the test in a low prevalence setting [8] may have led to false negative results as 11 of the subjects who tested negative reported a previously treated HCV infection. On the other hand, this is not a surprising finding given the well-known time-dependent reduction in HCV antibodies after HCV eradication [9].
Our findings revealed a fair number of HCV infections in people who were unaware of their serostatus, thus suggesting that rapid HCV testing in the context of SARS-CoV-2 screening programmes is a further means of achieving the WHO’s 2030 HCV elimination target [10]. If successful, other screening programmes for communicable diseases such as HIV infection could benefit from the same strategy.
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