Prophylaxe, Diagnostik und Therapie der Hepatitis-C-Virus(HCV)-Infektion

Improving the hepatitis C virus care cascade with the in-hospital Reflex tEsting ALarm-C (REAL-C) model

BACKGROUND

The World Health Organization (WHO) has set targets to eliminate viral hepatitis, including hepatitis C virus (HCV) infection, by 2030. We present the results of the in-hospital Reflex tEsting ALarm-C (REAL-C) model, which incorporates reflex HCV RNA testing and sending alerts to physicians.

METHODS

We conducted a retrospective study analysing the data of 1730 patients who newly tested positive for anti-HCV between March 2020 and June 2023. Three distinct periods were defined: pre-REAL-C (n = 696), incomplete REAL-C (n = 515) and complete REAL-C model periods (n = 519). The primary outcome measure was the HCV RNA testing rate throughout the study period. Additionally, we assessed the referral rate to the gastroenterology department, linkage time for diagnosis and treatment and the treatment rate.

RESULTS

The rate of HCV RNA testing increased significantly from 51.0% (pre-REAL-C) to 95.6% (complete REAL-C). This improvement was consistent across clinical departments, regardless of patients' comorbidities. Among patients with confirmed HCV infection, the gastroenterology referral rate increased from 57.1% to 81.1% after the REAL-C model. The treatment rate among treatment-eligible patients was 92.4% during the study period. The mean interval from anti-HCV positivity to HCV RNA testing decreased from 45.1 to 1.9 days. The mean interval from the detection of anti-HCV positivity to direct-acting antiviral treatment also decreased from 89.5 to 49.5 days with the REAL-C model.

CONCLUSION

The REAL-C model, featuring reflex testing and physician alerts, effectively increased HCV RNA testing rates and streamlined care cascades. Our model facilitated progress towards achieving WHO's elimination goals for HCV infection.

[The status of national and global hepatitis C elimination]

BACKGROUND

In 2016, the World Health Organization propagated the elimination of hepatitis C virus (HCV) by 2030 in order to address the public health threat posed by viral hepatitis. This article looks at the progress that has been made globally and in Germany since 2016.

METHODS

A selective literature search was conducted, with particular focus on studies and reviews relating to the elimination of hepatitis C infection both globally and in Germany.

RESULTS

In 2020, 56.8 million HCV infections were counted worldwide, which corresponds to a decline of 6.8 million since 2015. Countries that made a significant contribution to the elimination figures during this period included Egypt, Georgia, and Iceland, which were able to drastically reduce the number of HCV infections by means of national commitment in politics and healthcare. With regard to the status of elimination in Germany, the inclusion of screening for viral hepatitis in the general health check-up ("Check-up 35") in 2022/2023 has led to a significant increase in HCV case numbers. Globally and in Germany, men who have sex with men, intravenous drug users, migrants, and prison inmates are particularly vulnerable groups with regard to HCV infection.

CONCLUSION

In order to sustainably eliminate HCV, it is necessary to optimize education and prevention strategies in risk groups. With regard to the subgroup of prison inmates, political measures must be used to create a standardized approach in prison medicine. At a global level, elimination in low- and middle-income countries needs to be promoted in the future.

Current Therapy of Chronic Viral Hepatitis B, C and D

The majority of chronic viral hepatitis cases are induced via infection with the hepatitis B virus (HBV), hepatitis C virus (HCV), or hepatitis D virus (HDV). These patients are at increased risk for progressive liver disease leading to cirrhosis as well as hepatocellular carcinoma (HCC). HBV infection is well controlled by the currently available nucleosides as well as nucleotides, and the development of cirrhosis can be prevented. Additionally, it has been shown that HBV-induced liver fibrosis can regress during successful antiviral treatment; however, a "functional cure", i.e., loss of HBsAg, is a rare event when these drugs are used. Therefore, novel therapeutic strategies are aiming at the selective suppression of HBsAg levels in combination with immunostimulation. The development of directly acting antivirals (DAAs) has revolutionized HCV therapy, as almost all patients can be cured via this treatment. Additionally, DAA therapy has few, if any, side effects, and is generally well tolerated by patients. HDV remains the most challenging type of chronic viral hepatitis. Although novel therapeutic options have recently been approved, response rates are still less favorable compared to HBV and HCV. This review discusses current and future options for the treatment of chronic HBV, HCV, and HDV infection.

[Treatment of parenterally transmittable viral hepatitis]

Die parenteral übertragbaren Hepatitiden B/D und C und deren Komplikationen sind sowohl weltweit als auch in Deutschland ein nicht zu unterschätzendes Problem. Aufgrund der hohen Dunkelziffer, einer weiteren Verbreitung, insbesondere durch Drogenmissbrauch, steigender Prävalenzen im Rahmen der Immigration sowie einer pandemiebedingten verzögerten Diagnostik stellt die Identifizierung der erkrankten und somit potenziell infektiösen Patienten eine große Herausforderung für das Gesundheitswesen dar. Therapeutisch stehen sowohl bei der Hepatitis B als auch der Hepatitis C hochwirksame, praktisch nebenwirkungsfreie Therapiekonzepte mit einer einmal täglichen Tabletteneinnahme zur Verfügung. Für die Hepatitis B handelt es sich in der Mehrzahl der Fälle um eine Dauertherapie zur Suppression der Replikation, während es bei der Hepatitis C innerhalb weniger Wochen zur Viruselimination kommt. Ein neues Therapiekonzept mit Hemmung der Virusaufnahme zur Behandlung der Hepatitis D steht seit September 2020 erstmals zur Verfügung. Für alle Patienten gilt, dass bei einem eingetretenen fortgeschrittenen Leberschaden oder gar einer Leberzirrhose langfristig eine weitere Überwachung insbesondere zum Ausschluss eines Leberzellkarzinoms notwendig ist.

Regulatory Role of Phospholipids in Hepatitis C Virus Replication and Protein Function

Positive-strand RNA viruses such as hepatitis C virus (HCV) hijack key factors of lipid metabolism of infected cells and extensively modify intracellular membranes to support the viral lifecycle. While lipid metabolism plays key roles in viral particle assembly and maturation, viral RNA synthesis is closely linked to the remodeling of intracellular membranes. The formation of viral replication factories requires a number of interactions between virus proteins and host factors including lipids. The structure-function relationship of those proteins is influenced by their lipid environments and lipids that selectively modulate protein function. Here, we review our current understanding on the roles of phospholipids in HCV replication and of lipid-protein interactions in the structure-function relationship of the NS5A protein. NS5A is a key factor in membrane remodeling in HCV-infected cells and is known to recruit phosphatidylinositol 4-kinase III alpha to generate phosphatidylinositol 4-phosphate at the sites of replication. The dynamic interplay between lipids and viral proteins within intracellular membranes is likely key towards understanding basic mechanisms in the pathobiology of virus diseases, the mode of action of specific antiviral agents and related drug resistance mechanisms.

[Epidemiology of viral hepatitis A to E in Germany]

Viral hepatitis A to E describes various infectious inflammations of the liver parenchyma that are caused by the hepatitis viruses A to E (HAV, HBV, HCV, HDV, and HEV). Although the clinical pictures are similar, the pathogens belong to different virus families and differ in terms of pathogenesis, transmission routes, clinical course, prevention, and therapy options. In Germany, there is mandatory reporting according to the Infection Protection Act (IfSG) for direct or indirect laboratory evidence and for suspicion, illness, and death of viral hepatitis. The data are transmitted to the Robert Koch Institute.In this article, on the basis of published studies and notification data, we describe the epidemiology of hepatitis A to E as well as current challenges and prevention approaches. In particular, the latter contains the improvement of existing vaccination recommendations (hepatitis A and B); improvement of access to prevention, testing, and care including therapy with antiviral drugs (hepatitis B, C, and D) and the detection and prevention of foodborne infections and outbreaks; and improvements in the field of food safety (hepatitis A and E).

[Viral hepatitis A to E: prevalence, pathogen characteristics, and pathogenesis]

Bei der viralen Hepatitis handelt es sich um eine akute oder chronische Entzündung der Leber, die durch verschiedene Viren verursacht wird. Weltweit leiden derzeit ca. 325 Mio. Menschen an der chronischen Form. Jährlich versterben insgesamt ca. 1,6 Mio. an den Folgen einer viralen Hepatitis. Die Hepatitisviren werden in 5 Erregergruppen unterteilt, die mit den Buchstaben A bis E bezeichnet werden (HAV–HEV). Diese unterscheiden sich in Phylogenie, Übertragung, Epidemiologie, Wirtsspezifität, Lebenszyklus, Struktur und in speziellen Aspekten der Pathogenese.

Das strikt humanpathogene HAV, Teil der Familie Picornaviridae, induziert meist nur akute Hepatitiden und ist primär in Entwicklungsländern verbreitet. Das den Hepeviridae zugeordnete HEV beschreibt eine ähnliche Epidemiologie, ist jedoch durch sein zoonotisches Potenzial auch in Industrienationen weitverbreitet und kann zusätzlich eine chronische Erkrankung induzieren. Eine Chronifizierung tritt ebenso bei dem weltweit verbreiteten HBV (Hepadnaviridae) auf, dessen Satellitenvirus HDV (Kolmioviridae) das vorhandene kanzerogene Potenzial noch einmal erhöht. Das ebenfalls weltweit verbreitete HCV (Flaviviridae) birgt ein äußerst hohes Risiko der Chronifizierung und somit ebenfalls ein stark erhöhtes, kanzerogenes Potenzial.

Die Erreger der viralen Hepatitis unterscheiden sich in ihren Eigenschaften und Lebenszyklen. Eine differenzierte Betrachtung im Hinblick auf Epidemiologie, Nachweismethoden und Prävention ist daher angezeigt. Obwohl robuste Therapien, und im Falle einzelner Erreger auch Vakzine, vorhanden sind, muss die Forschung insbesondere in Hinblick auf die armutsassoziierten Erreger erheblich vorangetrieben werden.

From Screening to Therapy: Anti-HCV Screening and Linkage to Care in a Network of General Practitioners and a Private Gastroenterology Practice

(1) Background: Low rates of hepatitis C virus (HCV) diagnosis and sub-optimal linkage to care constitute barriers toward eliminating the infection. In 2012/2013, we showed that HCV screening in primary care detects unknown cases. However, hepatitis C patients may not receive further diagnostics and therapy because they drop out during the referral pathway to secondary care. Thus, we used an existing network of primary care physicians and a practice of gastroenterology to investigate the pathway from screening to therapy. (2) Methods: HCV screening was prospectively included in a routine check-up of primary care physicians who cooperated regularly with a private gastroenterology practice. Anti-HCV-positive patients were referred for further specialized diagnostics and treatment if indicated. (3) Results: Seventeen primary care practices screened 1875 patients. Twelve individuals were anti-HCV-positive (0.6%), six of them reported previous antiviral HCV therapy, and one untreated patient was HCV-RNA-positive (0.05% of the population). None of the 12 anti-HCV-positive cases showed up at the private gastroenterology practice. Further clinical details of the pathway from screening to therapy could not be analyzed. (4) Conclusions: The linkage between primary and secondary care appears to be problematic in the HCV setting even among cooperating partners, but robust conclusions require larger datasets.

Pharmacotherapy Profiles in People with Opioid Use Disorders: Considerations for Relevant Drug-Drug Interactions with Antiviral Treatments for Hepatitis C

People who inject drugs (PWID) are often affected by physical and psychological diseases and prone to co-medication. In Germany, about 50% of PWID are on opioid substitution therapy (OST). Comprehensive data on pharmacotherapy in these patients may help to select antiviral therapy against hepatitis C virus (HCV) infections and avoid drug–drug interactions (DDIs). We compared co-medication profiles based on statutory health insurance prescriptions (IQVIA database) of PWID (n = 16,693), OST (n = 95,023) and treated HCV patients (n = 7886). Potential DDIs with the most widely used HCV direct-acting agents (Sofosbuvir/Velpatasvir, Glecaprevir/Pibrentasvir and Elbasvir/Grazoprevir) were evaluated based on the Liverpool DDI database. Co-medication was present in 57% of PWID, 57% of OST, 44% of patients on HCV therapy and 46% in a subgroup receiving OST+HCV therapy (n = 747 of 1613). For all groups, co-medication belonging to ATC-class N (nervous system) was most commonly prescribed (in 75%, 68%, 41% and 62% of patients, respectively). Contraindications (i.e., DDIs precluding HCV therapy) were infrequent (0.4–2.5% of co-medications); potential DDIs with HCV therapies were shown for 13–19% of co-medications, namely for specific substances including some analgesics, antipsychotics, anticoagulants, lipid lowering drugs and steroids. In conclusion, concomitant pharmacotherapy is common and clinically relevant when treating HCV infection in PWID.