Late presentation of chronic HBV and HCV patients seeking first time specialist care in Spain: a 2-year registry review

Characterizing Hepatitis Delta in Spain and the gaps in its management

BACKGROUND AND AIMS

Chronic hepatitis D (CHD) is a severe form of chronic viral hepatitis. The estimated hepatitis delta prevalence in Spain is around 5% of patients with hepatitis B. Reimbursement of new antiviral therapies (Bulevirtide, BLV) was delayed in our country until February 2024. We aimed to characterize the clinical profile of patients with HDV/HBV infection in Spain and current barriers in their management at the time of BLV approval.

METHOD

Multicenter registry including patients with positive anti-HDV serology actively monitored in 30 Spanish centers. Epidemiological, clinical and virological variables were recorded at the start of follow-up and at the last visit.

RESULTS

We identified 329 anti-HDV patients, 41% were female with median age 51 years. The most common geographical origin was Spain (53%) and East Europe (24%). Patients from Spain were older and had HCV and HIV coinfection probably associated to past drug injection (p<0.01). HDV-RNA was positive in 138 of 221 assessed (62%). Liver cirrhosis was present at diagnosis in 33% and it was more frequent among viremic patients (58% vs 25%, p<0.01). After a median follow-up of 6 (3-12) years, 44 (16%) resolved infection (18 spontaneously and 26 after Peg-INF). An additional 10% of patients developed cirrhosis (n=137) during follow-up (45% had portal hypertension and 14% liver decompensation). Liver disease progression was associated to persisting viremia.

CONCLUSION

One-third of the patients with CHD already have cirrhosis at diagnosis. Persistence of positive viremia is associated to rapid liver disease progression. Importantly, barriers to locally determine/quantify HDV-RNA were present.

Elimination of HCV Infection: Recent Epidemiological Findings, Barriers, and Strategies for the Coming Years

Hepatitis C is a disease for which in approximately 30 years we have gone from the discovery of the causative agent in 1989, to the introduction of direct-acting antiviral (DAAs) therapies starting from 2011, and to a proposal for its elimination in 2016, with some countries being on track for this goal. Elimination efforts, in the absence of a vaccine, rely on prevention measures and antiviral therapies. However, treatment rates have declined in recent years and are not considered adequate to achieve this goal at a global level. This poses a great epidemiological challenge, as HCV in many countries still causes a significant burden and most infected people are not yet diagnosed. Consequently, efforts are needed at different levels with common purposes: to facilitate access to screening and diagnosis and to improve linkage to care pathways. In this review, we discuss the latest epidemiological findings on HCV infection, the obstacles to its elimination, and strategies that are believed to be useful to overcome these obstacles but are applied unevenly across the world.

Implementing a new HCV model of care for people who use drugs

Background & Aims

An estimated 50 million individuals have chronic hepatitis C virus (HCV) infection worldwide and people who use drugs (PWUD) are disproportionately affected. Persistent stigma and discrimination make it challenging for PWUD to access healthcare, potentially hindering HCV elimination progress in this population. To mitigate healthcare access barriers in PWUD, an HCV care model that simplified screening and linkage to care pathways was developed and rolled out in the Balearic Islands, Spain.

Methods

The prospective multicentre community model of care was implemented in 21 centres serving PWUD. This model involved: (1) participant recruitment and HCV antibody screening onsite via a point-of-care anti-HCV test, phlebotomy, or laboratory records; (2) HCV RNA, HBsAg and anti-HIV testing via a dried blood spot or phlebotomy; (3) linkage to specialist care and treatment prescription via telemedicine, when required; and (4) onsite monitoring of: (a) sustained virologic response (SVR) 4 and ≥12 weeks after treatment completion and; (b) potential new HCV infection or reinfection ∼1 year after phase 1 or SVR ≥12 monitoring. Care model acceptability was assessed.

Results

Between April 2021 and April 2023, 1,423 participants were recruited, of whom 464 (33%) were anti-HCV+ and 170 (12%) had detectable HCV RNA. Of the latter, 147 (86%) initiated therapy, of whom 124 (84%) completed it. SVR ≥12 monitoring was performed in 95 (77%) of these, of whom 88 (93%) had undetectable HCV RNA. Upon re-screening, four HCV reinfections were detected. Over 90% accepted study participation and screening and treatment decentralisation.

Conclusions

This adapted care model, which decentralised screening, diagnosis, and treatment, effectively increased healthcare access among PWUD, improving progress towards HCV elimination in this population in Spain.

Impact and implications

People who use drugs (PWUD) are among the most affected by chronic hepatitis C virus (HCV) infection globally. A simplified model of care was implemented in 21 centres serving this population across the Balearic Islands, Spain, to offer HCV care to 1,423 PWUD in 2021-2023. This decentralised screening, diagnosis, and treatment model resulted in an HCV cure rate of 93% of those who both completed therapy and were monitored post treatment completion. The Hepatitis C Free Balears model can guide the HCV elimination efforts of regional health authorities and other stakeholders in the rest of Spain and other parts of the world.

Clinical profile of Spanish hepatitisC virus-infected treatment-naïve patients with compensated cirrhosis in the CREST study

BACKGROUND AND AIM OF THE STUDY

There are still patients with hepatitisC in Spain who have yet to be diagnosed, but their clinical profile is unclear. In 2021, 21.93% of patients diagnosed had cirrhosis and were mostly treatment-naïve.

METHODS

This sub-analysis describes the clinical profile of the 60Spanish treatment-naïve patients with compensated cirrhosis who were included in the CREST study.

MAJOR RESULTS

Sixty percent of patients were male, median age 56years, and 33% had a history of drug use. Almost three-quarters (71.3%) had more than one comorbidity and 78.3% took concomitant medication. At treatment initiation, median platelet count was 139×103/μL and FibroScan® 17kPa. No virological failure was observed and no patient discontinued treatment due to adverse events. No clinically significant changes were noted during or after treatment in the median platelet, albumin, bilirubin, and transaminase levels.

CONCLUSIONS

Treatment with glecaprevir/pibrentasvir for 8weeks in this cohort of treatment-naïve patients with compensated cirrhosis in Spain was safe and effective. This information reinforces the use of this short antiviral regimen even when there is compensated cirrhosis, simplifying the approach to hepatitisC among those patients still to be diagnosed and treated in Spain.

A Longitudinal Analysis of Mortality Related to Chronic Viral Hepatitis and Hepatocellular Carcinoma in the United States

(1) Background: Hepatocellular carcinoma (HCC) contributes to the significant burden of cancer mortality in the United States (US). Despite highly efficacious antivirals, chronic viral hepatitis (CVH) remains an important cause of HCC. With advancements in therapeutic modalities, along with the aging of the population, we aimed to assess the contribution of CVH in HCC-related mortality in the US between 1999-2020. (2) Methods: We queried all deaths related to CVH and HCC in the multiple-causes-of-death files from the CDC Wide-ranging Online Data for Epidemiologic Research (WONDER) database between 1999-2020. Using the direct method of standardization, we adjusted all mortality information for age and compared the age-adjusted mortality rates (AAMRs) across demographic populations and by percentile rankings of social vulnerability. Temporal shifts in mortality were quantified using log-linear regression models. (3) Results: A total of 35,030 deaths were identified between 1999-2020. The overall crude mortality increased from 0.27 in 1999 to 8.32 in 2016, followed by a slight reduction to 7.04 in 2020. The cumulative AAMR during the study period was 4.43 (95% CI, 4.39-4.48). Males (AAMR 7.70) had higher mortality rates compared to females (AAMR 1.44). Mortality was higher among Hispanic populations (AAMR 6.72) compared to non-Hispanic populations (AAMR 4.18). Higher mortality was observed in US counties categorized as the most socially vulnerable (AAMR 5.20) compared to counties that are the least socially vulnerable (AAMR 2.53), with social vulnerability accounting for 2.67 excess deaths per 1,000,000 person-years. (4) Conclusions: Our epidemiological analysis revealed an overall increase in CVH-related HCC mortality between 1999-2008, followed by a stagnation period until 2020. CVH-related HCC mortality disproportionately affected males, Hispanic populations, and Black/African American populations, Western US regions, and socially vulnerable counties. These insights can help aid in the development of strategies to target vulnerable patients, focus on preventive efforts, and allocate resources to decrease HCC-related mortality.

Inequities in primary liver cancer in Europe: The state of play

Given the increasing burden of liver cancer in Europe, it is crucial to investigate how social determinants of health (SDoH) affect liver cancer risk factors and access to care in order to improve health outcomes equitably. This paper summarises the available evidence on the differential distribution of liver cancer risk factors, incidence, and health outcomes in the European Economic Area and the United Kingdom from an SDoH perspective. Vulnerable and marginalised populations have low socio-economic and educational levels and are the most affected by liver cancer risk factors. Reasons for this include varied access to hepatitis B virus vaccination and limited access to viral hepatitis B and C screening, harm reduction, and treatment. Additionally, alcohol-related liver disease remains highly prevalent among individuals with low education, insecure employment, economic instability, migrants, and deprived populations. Moreover, significant variation exists across Europe in the proportion of adults with steatotic liver disease, overweight/obesity, and diabetes, based on geographical area, gender, socio-economic and educational background, and density of ultra-processed food outlets. Inequities in cirrhosis mortality rates have been reported, with the highest death rates among individuals living in socio-economically disadvantaged areas and those with lower educational levels. Furthermore, insufficient healthcare access for key populations with primary liver cancer is influenced by complex healthcare systems, stigmatisation, discrimination, low education, language barriers, and fear of disclosure. These challenges contribute to inequities in liver cancer care pathways. Future studies are needed to explore the different SDoH-interlinked effects on liver cancer incidence and outcomes in European countries. The ultimate goal is to develop evidence-based multilevel public health interventions that reduce the SDoH impact in precipitating and perpetuating the disproportionate burden of liver cancer in specific populations.

Late presentation for hepatitis C treatment: prevalence and risk factors in the Swiss Hepatitis C Cohort

OBJECTIVE

Patients with 'late presentation' (LP) of chronic hepatitis C infection (HCV) have already developed advanced liver disease before receiving direct-acting antiviral (DAA) treatment. Even after successful treatment, the risk of morbidity and premature death remains elevated, leading to an unnecessary disease burden. This study aimed to assess the prevalence of LP within the prospective observational Swiss Hepatitis C Cohort (SCCS) and evaluate risk factors as determinants of LP.

METHODS

Treatment-naïve participants of SCCS who received DAA treatment between 2014 and 2019 were included. Demographic, clinical and behavioural data were compared between the LP and non-LP strata. LP prevalence was calculated over time and by year. LASSO regression was used to identify potential risk factors for LP, and odds ratios were calculated by refitting logistic regression models.

RESULTS

In this explorative, retrospective case-control study using data of n  = 5829 SCCS members, a total of 21.3% received their first HCV treatment. The cumulative LP prevalence decreased from mid-2015 and stabilised at 46.5% ( n  = 579) by the end of 2019. Male gender, higher age and a history of alcohol overuse were associated with a higher risk of LP.

CONCLUSION

Despite the study's limitations, LP prevalence was higher than anticipated, considering Switzerland's availability period and universal access to DAAs. Therefore, any HCV LP should be viewed as a healthcare system failure, primarily in high-income economies. As LP is directly linked to the disease burden, it must be included as a mandatory parameter in surveillance response systems of HCV elimination programs.

Community-based screening enhances hepatitis B virus linkage to care among West African migrants in Spain

BACKGROUND

Chronic infection with HBV is responsible for >50% of all hepatocellular cancer cases globally and disproportionately affects sub-Saharan African (sSA) countries. Migration from these countries to Europe has increased substantially in recent years, posing unique challenges to health systems. The aim of this study was to carry out a community-based intervention to increase HBV screening, vaccination, and linkage to care among sSA migrants in Catalonia, Spain.

METHODS

This was a prospective cohort study. Participants ≥18 years were offered community-based HBV screening between 20/11/20 and 21/01/22. Rapid HBV testing and blood sample collection utilizing plasma separation cards were carried out and linkage to care was offered to all participants. HBV vaccination and post-test counseling were performed at a second visit in the community. The main outcome was the odds of those with current HBV infection being successfully linked to hepatology. Rates of completing the care cascade of this model were analyzed.

RESULTS

In the present study, 444 people undergo screening, with 50.6% of participants showing evidence of past or current HBV infection, including an HBsAg prevalence of 9.2%. Migrants with current HBV infection exhibit 5.2 times higher odds of successful linkage to care compared to those in need of post-test counseling or vaccination. The study achieves a successful linkage to care rate of 72% for all participants, with specialist appointments arranged within 15.5 days.

CONCLUSIONS

This community-based HBV screening program provides evidence of a successful model for identifying and providing care, including vaccination, to west African migrants at high risk of HBV infection who may otherwise not engage in care.

Chronic conditions and multimorbidity among West African migrants in greater Barcelona, Spain

OBJECTIVES

This study aimed to report the prevalence and identify potential risk factors of chronic conditions among West African migrants living in the greater Barcelona area, Spain, and explore the relationship between years of residence in Spain and chronic disease burden.

METHODS

This cross-sectional study included 436 adult African migrants who participated in a community-based hepatitis B virus (HBV) screening and vaccination program (HBV-COMSAVA) in the greater Barcelona area from 21 November 2020 to 22 January 2022. Data were analyzed using standard descriptive statistics and bivariable and multivariable logistic regression.

RESULTS

HBV, non-communicable diseases (NCDs) and metabolic risk factors, and multimorbidity prevalence were 9.17, 20.87, and 4.13%, respectively. Being male or having been previously tested for HBV were associated with higher odds of HBV positivity. Associated risk factors for NCDs and metabolic risk factors included living in Spain for >5 years, being female, and being aged ≥50 years.

CONCLUSION

The high prevalence of chronic conditions in migrant populations supports a need for early detection strategies and tailored public health interventions that aim to reduce the disease burden imposed on migrants and on health systems in host countries.

Recommendations for the integral diagnosis of chronic viral hepatitis in a single analytical extraction

The Spanish Society of Digestive Pathology (SEPD), the Spanish Association for the Study of the Liver (AEEH), the Spanish Society of Infections and Clinical Microbiology (SEIMC) and its Viral Hepatitis Study Group (GEHEP), and with the endorsement of the Alliance for the Elimination of Viral Hepatitis in Spain (AEHVE), have agreed on a document to carry out a comprehensive diagnosis of viral hepatitis (B, C and D), from a single blood sample; that is, a comprehensive diagnosis, in the hospital and/or at the point of care of the patient. We propose an algorithm, so that the positive result in a viral hepatitis serology (B, C and D), as well as human immunodeficiency virus (HIV), would trigger the analysis of the rest of the virus, including the viral load when necessary, in the same blood draw. In addition, we make two additional recommendations. First, the need to rule out a previous hepatitis A virus (VHA) infection, to proceed with its vaccination in cases where IgG-type studies against this virus are negative and the vaccine is indicated. Second, the determination of the HIV serology. Finally, in case of a positive result for any of the viruses analyzed, there must be an automated alerts and initiate epidemiological monitoring.

Hepatitis C Virus Micro-Elimination Plan in Southern Italy: The "HCV ICEberg" Project

This study evaluates the feasibility of a local action program for HCV micro-elimination in highly endemic areas. Retrospective analysis: administrative and laboratory data (Local Health Unit, southern Italy) were integrated to quantize the anti-HCV-positive subjects not RNA tested and untreated HCV-infected subjects (2018-2022). Prospective analysis: all subjects admitted to a division of the LHU largest hospital (2021-2022) were tested for HCV, with linkage of active-infected patients to care. Overall, 49287 subjects were HCV-Ab tested: 1071 (2.2%) resulted positive without information for an HCV RNA test and 230 (0.5%) had an active infection not yet cured. Among 856 admitted subjects, 54 (6.3%) were HCV-Ab+ and 27 (3.0%) HCV RNA+. Of HCV-infected patients, 22.2% had advanced liver disease, highlighting the need for earlier diagnosis; 27.7% were unaware of HCV infection; and 20.4% were previously aware but never referred to a clinical center. Of these, 26% died and 74% received treatment. Our study emphasizes the value of an active HCV hospital case-finding program to enhance diagnosis in patients with several comorbidities and to easily link them to care. Our data strongly suggest extending this program to all hospital wards/access as a standard of care, particularly in highly endemic areas, to help HCV disease control and take steps in achieving the elimination goals.

Clinical Profile and Limitations in the Management of HBV Patients Attending Clinic at a District Hospital in Ghana

Background

Chronic hepatitis B (CHB) is estimated to cause between 500,000 and 1.2 million deaths worldwide every year through cirrhosis and hepatocellular carcinoma (HCC). Liver cirrhosis and HCC are the commonest liver diseases causing death in Ghana. The most critical problem in the management of CHB in sub-Saharan Africa is the high cost of investigations and antiviral drugs. There is scanty information concerning newly diagnosed CHB patients and their management challenges in Ghana. This study sought to determine the clinical characteristics and management challenges of CHB patients in Ghana. Methodology. A prospective cohort study was conducted involving newly diagnosed CHB patients being managed at St. Dominic Hospital. Patient demographic and clinical features were abstracted using a standardized questionnaire. The proportion of patients able to undertake investigations and treatment were determined, and the limitations to standard management were recorded. The performance of APRI score in the diagnosis of cirrhosis was also investigated.

Results

Of the 334 patients with newly diagnosed CHB, the median age at diagnosis was 35 (IQR 28-44) years. Less than a quarter (22.2%) were able to undertake viral load testing and 23.4% were eligible for treatment. Of those who were eligible for treatment, only 42.3% were able to initiate treatment. Almost a third of cases (32.1%) reported late with liver-related complications. The sensitivity of APRI score with cut-off value of 2 in the diagnosis of liver cirrhosis was 70.2% and specificity was 97.9%.

Conclusion

A high proportion of newly diagnosed CHB patients presented late and with liver-related complications. Majority were not able to afford viral load testing and antiviral medication. Screening of hepatitis B among the general population and inclusion of CHB management in the National Health Insurance Scheme should be encouraged.

A cascade of care analysis on the elimination of hepatitis C from public hospitals in Madrid

Background

Direct-acting antivirals can cure ≥95% of hepatitis C virus (HCV) cases, but do not reach everyone in need. This cross-sectional study analyses the HCV cascade of care (CoC) in Madrid, Spain, in high-risk patients, to inform micro-elimination measures.

Methods

From September 2019 to May 2021, data from medical records were collected and analysed from six public hospitals in Madrid, including seven adult, high-risk patient groups: patients in haemodialysis or pre-dialysis programmes, co-infected with HIV, with advanced liver disease (ALD), with hereditary haematological diseases, with transplants and people who inject drugs (PWID).

Results

Here we present an analysis of 3994 patients (68.8% male), 91.2% were tested for anti-HCV and 28.9% were positive. Of the total, 34.5% were tested for HCV–RNA and 62.4% of these were positive. Of those HCV–RNA positive, 98.0% were treatment-eligible: in 7.4%, treatment is ongoing and in 89.3% completed. Of the latter, 92.2% obtained a sustained virological response 12 weeks post treatment (SVR12). Of those with ongoing or completed treatment, 9.8% experienced loss to follow-up (LTFU) or had unknown SVR12, 50.3% developed hepatic and 20.3% extrahepatic complications. ALD patients had the highest proportion of HCV–RNA positives (32.5%). The lowest proportion of patients treated were PWID (85.2%).

Conclusions

Almost one in ten high-risk patients in six of Madrid’s public hospitals remains untested for HCV antibodies. An almost equal percentage of those untested have experienced LTFU, with the highest proportion in PWID. This approach to monitoring the HCV CoC is vital to inform measures to eliminate HCV in hospitals.

Despite the existence of effective treatments with few side effects for hepatitis C virus (HCV), such treatments do not reach everyone in need and this means we cannot eliminate HCV. Here, we analysed HCV diagnoses, patients’ access to care and treatment rates in high-risk populations in major public hospitals in Madrid. Data were collected from adult patients in haemodialysis or pre-dialysis programmes, co-infected with HIV, with advanced liver disease, with hereditary haematological diseases, with transplants and people who inject drugs (PWID). Nearly 10% of high-risk patients in six of Madrid’s public hospitals did not have an initial test for HCV. An almost equal percentage of those who were not tested for HCV have not continued to be followed for care, primarily PWID. This approach to monitoring the HCV cascade of care is vital to inform measures to eliminate HCV in hospitals.

Lazarus et al. evaluate the cascade of care for people with hepatitis C virus (HCV) treated within six public hospitals in Madrid, Spain. The authors report on potential gaps in care in specific populations, including inadequate testing and loss to follow-up, and their implications on HCV micro-elimination in Madrid.