How close are we to hepatitis C virus elimination in Central Europe?

Global Elimination of HCV-Why Is Poland Still So Far from the Goal?

INTRODUCTION

Eradication of HCV in the global population remains one of the greatest challenges faced by the WHO. An insufficient level of knowledge and the lack of a national screening test strategy are obstacles to HCV eradication.

AIM

This work aimed to summarize surveys assessing risk factors and awareness of the respondents regarding the prevention and course of HCV infection. The summary also includes the most important European and global attempts at eliminating HCV.

MATERIALS AND METHODS

A cross-sectional, population-based study was conducted in the Mazowieckie district in Poland using anonymous surveys and conducted on people who willingly reported for a test.

RESULTS

In the study cohort of n = 7397 adults, there were 5412 women (73.16%). The analysis of the quota sample (n = 1303) reflected the actual proportions in the population of the Mazowieckie Voivodeship.

CONCLUSIONS

Insufficient knowledge about HCV decreases the probability of higher detection of infections, fast diagnostics, and treatment. According to the WHO model, assuming a 90% detection rate and treatment of 80% of infected by 2030, and taking into account 120-150 thousand infected persons in Poland, the number of detections of HCV should be increased 4-5 times and all diagnosed persons should be offered antiviral treatment.

Genotype Distribution and Characteristics of Chronic Hepatitis C Infection in Estonia, Latvia, Lithuania, and Ukraine: The RESPOND-C Study

Background and objectives: Since 2013, highly effective direct-acting antiviral (DAA) treatment for chronic hepatitis C (CHC) has become available, with cure rates exceeding 95%. For the choice of optimal CHC treatment, an assessment of the hepatitis C virus (HCV) genotype (GT) and liver fibrosis stage is necessary. Information about the distribution of these parameters among CHC patients in Estonia, Latvia, and Lithuania (the Baltic states) and especially in Ukraine is scarce. This study was performed to obtain epidemiologic data regarding CHC GT and fibrosis stage distribution for better planning of resources and prioritization of patients for DAA drug treatment according to disease severity in high-income (the Baltic states) and lower-middle-income (Ukraine) countries. Materials and methods: The retrospective RESPOND-C study included 1451 CHC patients. Demographic and disease information was collected from medical charts for each patient. Results: The most common suspected mode of viral transmission was blood transfusions (17.8%), followed by intravenous substance use (15.7%); however, in 50.9% of patients, the exact mode of transmission was not clarified. In Ukraine (18.4%) and Estonia (26%), transmission by intravenous substance use was higher than in Lithuania (5%) and Latvia (5.3%). Distribution of HCV GT among patients with CHC was as follows: GT1-66.4%; GT3-28.1; and GT2-4.1%. The prevalence of GT1 was the highest in Latvia (84%) and the lowest in Ukraine (63%, p < 0.001). Liver fibrosis stages were distributed as follows: F0-12.2%, F1-26.3%, F2-23.5%, F3-17.1%, and F4-20.9%. Cirrhosis (F4) was more prevalent in Lithuanian patients (30.1%) than in Estonians (8.1%, p < 0.001). Conclusions: This study contributes to the knowledge of epidemiologic characteristics of HCV infection in the Baltic states and Ukraine. The data regarding the patterns of HCV GT and fibrosis stage distribution will be helpful for the development of national strategies to control HCV infection in the era of DAA therapy.

Real-World Effectiveness and Safety of Direct-Acting Antivirals in Patients with Chronic Hepatitis C and Epilepsy: An Epi-Ter-2 Study in Poland

INTRODUCTION

In Poland, active HCV infection affects between 0.4 and 0.5% of the population, i.e., about 150,000 people, while the number of patients with epilepsy is estimated to be 350,000-400,000. Currently available antiviral therapies show little interaction with neurological drugs. The aim of our study was to evaluate the effectiveness and safety of the treatment of chronic HCV infection in patients with coexisting epilepsy.

METHODS

A total of 184 epilepsy patients were selected from the group of 10,152 HCV-infected patients treated for HCV infection within the Epiter-2 database from 2015 to 2018. Comparing the effectiveness and safety of anti-HCV regimens between the patients with comorbid epilepsy and 3573 patients without comorbidities was our study's objective.

RESULTS

The effectiveness of anti-HCV treatment was high in both the sample and the control group. No statistically significant SVR difference was observed between the sample group, with ITT = 93.5% and mITT = 95.5%, and the control group, with ITT = 95.2% and mITT = 97.5%, regardless of the genotype and the stage of liver disease at the start of therapy. The treatment was safe in patients with epilepsy.

CONCLUSIONS

The effectiveness and safety of HCV treatment in patients with epilepsy are comparable to those of patients with no significant comorbidities.

Changing Epidemiological Patterns of Infection and Mortality Due to Hepatitis C Virus in Poland

INTRODUCTION

Limited information is available on trends in hepatitis C virus (HCV) infection, particularly in Central Europe. To address this knowledge gap, we analyzed HCV epidemiology in Poland, considering socio-demographic characteristics, changing patterns over time, and the impact of the COVID-19 pandemic.

MATERIAL AND METHODS

We examined HCV cases (diagnosis and deaths) reported by national registries and used joinpoint analysis to estimate time trajectories.

RESULTS

Between 2009 and 2021, there were changes in the trends of HCV, shifting from positive to negative in Poland. Among men, there was a significant increase initially in diagnosis rate of HCV in rural areas (annual percent change, APC_2009-2016 +11.50%) and urban areas (APC_2009-2016 +11.44%) by 2016. In subsequent years until 2019, the trend changed direction, but the reduction was weak (P_trend > 0.05) in rural areas (-8.66%) and urban areas (-13.63%). During the COVID-19 pandemic, the diagnosis rate of HCV dramatically decreased in rural areas (APC_2019-2021 -41.47%) and urban areas (APC_2019-2021 -40.88%). Among women, changes in the diagnosis rate of HCV were less pronounced. In rural areas, there was a significant increase (APC_2009-2015 +20.53%) followed by no significant change, whereas changes occurred later in urban areas (APC_2017-2021 -33.58%). Trend changes in total mortality due to HCV were mainly among men, with a significant decrease in rural (-17.17%) and urban (-21.55%) areas from 2014/2015.

CONCLUSIONS

The COVID-19 pandemic reduced HCV diagnosis rates in Poland, especially for diagnosed cases. However, further monitoring of HCV trends is necessary, along with national screening programs and improved linkage to care.

Hepatitis C Virus Epidemiology in Lithuania: Situation before Introduction of the National Screening Programme

In 2022, the Lithuanian health authorities decided to pay general practitioners a fee for performing serological tests for hepatitis C virus (HCV) antibodies in the population born from 1945 to 1994 once per life and annual HCV testing for PWID and HIV infected patients. This study aimed to assess trends in HCV-related mortality in the country and the prevalence of HCV infection among patients with liver diseases and evaluate possibilities of screening for HCV infection at a primary health care center. Age-standardized mortality rates in 2010–2020 were calculated for deaths caused by chronic hepatitis C and some liver diseases. Data on HCV infection among patients with liver cirrhosis, cancer and transplant patients were collected from the tertiary care hospital Kauno Klinikos. The prevalence of anti-HCV and risk factors of HCV infection was assessed among patients registered with the health care center in Klaipeda, where a pilot study of screening was performed. No steady trend in mortality was observed. Analysis of medical documentation showed that 40.5% of patients with liver cirrhosis, 49.7% with cancers and 36.9% of transplant patients were HCV infected. Over the year, 4867 patients were screened in the primary health care center. Positive anti-HCV prevalence was 1.7% (2.1% in men and 1.3% in women). Blood transfusion and being a blood donor before 1993 also having tattoos were associated with higher odds of HCV infection. The study revealed the active participation of individuals in HCV screening.

HCV Elimination in Central Europe with Particular Emphasis on Microelimination in Prisons

In 2016, the WHO announced a plan to eliminate viral hepatitis as a public health threat by 2030. In this narrative review, experts from Bulgaria, Croatia, the Czech Republic, Hungary, Latvia, Lithuania, Poland and Slovakia assessed the feasibility of achieving the WHO 2030 target for HCV infections in Central Europe. They focused mainly on HCV micro-elimination in prisons, where the highest incidence of HCV infections is usually observed, and the impact of the COVID-19 pandemic on the detection and treatment of HCV infections. According to the presented estimates, almost 400,000 people remain infected with HCV in the analyzed countries. Interferon-free therapies are available ad libitum, but the number of patients treated annually in the last two years has halved compared to 2017–2019, mainly due to the COVID-19 pandemic. None of the countries analyzed had implemented a national HCV screening program or a prison screening program. The main reason is a lack of will at governmental and prison levels. None of the countries analyzed see any chance of meeting the WHO targets for removing viral hepatitis from the public threat list by 2030, unless barriers such as a lack of political will and a lack of screening programs are removed quickly.

Five-Year Follow-Up of Cured HCV Patients under Real-World Interferon-Free Therapy

(1) Background: Treatment of hepatitis C virus (HCV) infections with direct-acting antivirals (DAA) has demonstrated high efficacy and an excellent safety profile. The cured patients showed a sustained virological response and improved liver function, but also a continued risk of hepatocellular carcinoma (HCC) during the 2-3 years of follow-up after treatment; (2) Methods: A total of 192 patients out of 209 of the primary AMBER study were analyzed five years after treatment with ombitasvir/paritaprevir/ritonavir with or without dasabuvir and with or without ribavirin. Results: We confirmed that HCV clearance after DAA treatment is stable regardless of baseline liver fibrosis. We found that sustained virologic response is associated with a gradual but significant reduction in liver stiffness over 5 years. Liver function improved during the first 2 years of follow-up and remained stable thereafter. The risk of death due to HCC as well as death due to HCV persists through 5 years of follow-up after successful DAA treatment. However, in non-cirrhotic patients, it appears to clear up 3 years after treatment; (3) Conclusions: Monitoring for more than 5 years after curing HCV infection is necessary to assess the long-term risk of possible development of HCC, especially in patients with cirrhosis of the liver.

Is elimination of HCV in 2030 realistic in Central Europe

According to the recent data presented by Central-European HCV experts, the estimated prevalence of HCV is between 0.2% and 1.7% in certain countries in this region. There are no financial limitations to access to treatment in most countries. Patients in these countries have access to at least one pangenotypic regimen. The most common barriers to the elimination of HCV in Central Europe are a lack of established national screening programmes and limited political commitment to the elimination of HCV. Covid-19 has significantly affected the number of patients who have been diagnosed and treated, thus, delaying the potential elimination of HCV. These data suggest that the elimination of HCV elimination projected by WHO before 2030 will not be possible in the Central Europe.

Viral hepatitis C pandemic: Challenges and threats to its elimination

Under the WHO plan, the global elimination of the HCV pandemic is scheduled for 2030. The burden of HCV infection in developed countries is largely borne by people who inject drugs (PWID): new infections and reinfections are related to their risky behaviour. Although safe and sensitive hepatitis C diagnostic tools and directly acting antiviral medication are widely used, major challenges to disease elimination still remain in developed countries, where the WHO plan is in progress. The challenge is in the involvement and engagement of infected PWID. There is a strong need to change our uptake and treatment strategies to address all patients from the risk groups, connect them with the healthcare system and cure them with the vision to eliminate this HCV pandemic.

CHRONIC HEPATITIS C PATIENTS LOST IN THE SYSTEM: PREDICTIVE FACTORS OF NON-REFERRAL OR LOSS OF FOLLOW UP TO HEPATOLOGY UNITS

INTRODUCTION

Several barriers remain in the hepatitis C care cascade, which need to be removed in order to eliminate Chronic Hepatitis C. These barriers include deficiencies in screening and confirmatory diagnosis as well as difficulties in accessing treatment.

AIMS

To identify factors associated with the non-referral of patients with positive HCV-antibody and to identify factors associated with loss of follow-up or non-attendance of these patients to specialist consultation after their referral.

METHODS

Observational and retrospective single-centre-study, including all positive HCV serologies performed between January 2013 and May 2018 in the Virgen Macarena health area before implementing the one-step diagnosis. Non-referred patients and patients who were lost to follow-up after being referred were identified.

RESULTS

A total of 54 (77.4%) patients diagnosed in PC and 54 (22.2%) from hospital specialists were not referred (p <0.001). Predictors for non-referral were: stay in prison/ institutionalized (p = 0.04), suffering COPD (p = 0.07), a normal AST value (p = 0.034) or test requested by PCP (p = 0.004). Patients referred from PC were more likely to be lost to follow-up than those referred from hospital specialists (p <0.001). Predictors for loss of follow-up included: opioid replacement therapy (p = 0.034), absence of high blood pressure (p = 0.039) and test requested by PCP (p = 0.049).

CONCLUSIONS

A high percentage of patients with positive HCV serology were not referred or lost follow-up, mainly those belonging to high risk social groups or those with associated comorbidities. Patients with average values of transaminases or those diagnosed in primary care were also less referred.

Searching for the optimal population for hepatitis C virus screening in Poland

Aim of the study

The purpose of the study was to select the optimal target population for a possible national hepatitis C virus (HCV) screening program in Poland, based on the most recent available data.

Material and methods

The analysis included 723,654 participants from different populations screened for anti-HCV. Testing was performed in the whole blood using rapid anti-HCV kits. Presence of HCV RNA was additionally demonstrated in some anti-HCV positive patients with the real-time polymerase chain reaction method.

Results

Altogether 3,548 anti-HCV positive individuals were identified, so the prevalence rate in the whole studied population was 0.5%. The highest percentage (1.2%) was shown by diagnostic laboratories, which offered rapid testing for patients visiting their offices during the HCV awareness campaign. Relatively high anti-HCV prevalence of 0.6-0.7% was noted in hospitals and in private medical centers, as well as during music concerts. Surprisingly, the lowest prevalence (0.2%) was observed in general practitioners’ offices. Among 502 anti-HCV positive individuals tested additionally for HCV RNA, viremic presence was demonstrated in 40%.

Conclusions

Anti-HCV testing in Poland should be carried out using rapid anti-HCV kits at the patients’ admission to the hospitals and should also be offered to patients during their visits for any purpose in diagnostic laboratories or private medical centers.