COVID-19 impacts global targets to eliminate viral hepatitis
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In May, WHO released a 112-page progress report that detailed gaps in the efforts to eliminate HIV, hepatitis and STIs by 2030.
“Some of these gaps have been widened by the COVID-19 pandemic, but even before this crisis, we were not on track to reach our elimination targets by 2030,” WHO Director General Tedros Adhanom Ghebreyesus, PhD, MSc, said during a press briefing.
Source: Cary James
Researchers reported in the American Journal of Preventive Medicine that the pandemic led to major decreases in HCV virus testing and treatment, including a 59% decrease in HCV antibody testing volume in April 2020 compared with the previous 2 years.
There have been other indications that the pandemic has impeded the fight against viral hepatitis, including a World Hepatitis Alliance (WHA) survey that assessed the impact- of COVID-19 on the WHO 2030 targets, which include a 90% reduction in new cases of HBV and HCV and a 65% reduction in deaths from the infections.
In all, there were 132 respondents to the WHA survey representing frontline hepatitis service providers in 32 countries. From March 30 to May 4, 2020, 94% reported that their services were impacted by the COVID-19 crisis, and just 36% said people were able to access viral hepatitis testing, mostly because of closed testing facilities, according to results published in TheLancet Gastroenterology and Hepatology.
We asked experts to describe the ground-level impact that the pandemic has had on viral hepatitis services and what can be done to overcome any negative effects.
‘Every opportunity should be seized’
The authors of the report in TheLancet Gastroenterology and Hepatology said the inability of patients to access their medications “will undoubtedly cause increased anxiety among people living with viral hepatitis.”
“Every opportunity should be seized to identify the 290 million people living with viral hepatitis who are unaware of their status,” WHA communications director Chris Wingrove and colleagues wrote. “As countries look to increase testing capacity for COVID-19, they must consider existing programs led by civil society networks to enable the rapid scale-up needed.”
They said community organizations can test for viral hepatitis and COVID-19 at the same time.
“From this crisis, we have an opportunity to evolve health systems to better serve us all. Hepatitis elimination must not be left behind,” they wrote.
The Coalition for Global Hepatitis Elimination (CGHE) also surveyed clinicians and program managers about changes to hepatitis testing and treatment services and strategies to decrease transmission. According to a report in Clinical Liver Disease, respondents included 103 clinicians and program managers from 44 countries comprising six WHO regions.
The 53-question survey covered HBV and HCV services delivered before the emergence of COVID-19, during the months impacted by COVID-19, and the month of survey completion; and mitigation strategies.
According to CGHE director John W. Ward, MD, and colleagues, the survey showed that the pandemic decreased hepatitis services, including 39% and 21% of respondents who reported a more than 50% decline in treatment volumes for HCV and HBV, respectively, and nearly 30% who reported more than 50% declines in HCV or HBV screening.
However, Ward and colleagues said the pandemic “created new opportunities to strengthen hepatitis elimination efforts.”
“The COVID-19 response resulted in clinicians adopting strategies — larger refills, less imaging and lab testing and telehealth contact with patients — that can be in place to improve access to hepatitis care after cases of COVID-19 wane,” Ward said in an interview.
The WHA survey results demonstrated 52% of respondents from low- and middle-income countries were unable to access treatment when the pandemic started.
“One of the major contributors for this was people avoiding health care facilities due to COVID-19,” WHA CEO Cary James told Infectious Disease News.
According to James, one positive during the COVID-19 pandemic is that in some countries, patients accessing hepatitis treatment have received longer courses of medication.
“It enables people to access medications more easily and hopefully will be a practice that continues,” James said.
Anna S. Lok, MD, a professor of internal medicine and director of clinical hepatology at University of Michigan, said many people with hepatitis who were set to begin treatment instead did not because they were not comfortable going to a clinic or a lab for blood work. Although these patients have turned to telemedicine, she said remote care does not work for everyone.
Lok said she was able to provide her patients some sort of care through virtual visits and convinced many to complete their lab work.
“We have patients even now who absolutely have missed getting tested for almost a year, and I just cannot convince them,” Lok told Infectious Disease News.
In addition to a decrease in hepatitis prevention, testing and treatment services, James said countries may begin reassessing their health expenditure in light of an “uncertain global financial outlook created by the pandemic.”
“Despite hepatitis elimination being a financially prudent investment, countries may reduce funding for hepatitis programs,” he said. “It is crucial that this is not allowed to happen and that countries are supported to increase hepatitis programs and to reach the elimination goals.”
Lok said the impact of COVID-19 will be different for each country.
“The first thing is everyone’s attention has been rightfully shifted,” Lok said. “Our attention has been diverted. For those of us who have been predominantly working on hepatitis, our attention and focus has shifted. Our ability to take care of our patients has been changed.”
Continuing elimination efforts
Ward said that throughout the pandemic, the CGHE found ways to continue its efforts to eliminate hepatitis.
The WHA has:
- prepared a synthesis of the correlation between COVID-19 and liver disease;
- prepared a report on the epidemiology of COVID-19 and a list of recommendations for care of patients with liver disease during the pandemic;
- at international meetings, presented on changes in access to hepatitis clinical services;
- presented at a side event at the United Nations General Assembly to assess the impact of COVID-19 and potential opportunities for hepatitis testing and linkage to care;
- developed a survey to evaluate changes in clinical practice during the response to COVID-19; and
- reported how communities are taking advantage of improvements in housing for the homeless and other responses to the COVID-19 pandemic to increase access to HCV testing for marginalized populations.
“During the pandemic, our members have continued to support their communities, adapting their services against the dual threats of COVID-19 and viral hepatitis,” James said. “WHA has been championing their work and highlighting the need to support them throughout the pandemic.”
James said this included delivering services online, delivering medication to patients’ homes and delivering essential foods and protective equipment to those who were most vulnerable.
Impact of social isolation
Julius Wilder, MD, an assistant professor of medicine at Duke University, noted that social isolation related to the pandemic has contributed to issues that “intersect with chronic liver disease, including hepatitis C.”
“We have seen increases with respect to drug abuse, which of course is a key driver of new hepatitis C diagnoses in the United States,” he told Infectious Disease News. “We have seen an increase with respect to alcohol abuse, which is extremely important in patients who have other forms of liver disease because of the negative effects that alcohol has on people with liver problems.”
These things, in addition to barriers to care, create a “perfect storm” for patients with chronic liver disease, Wilder said.
This is true for “any chronic liver disease, but particularly hepatitis C because of its interaction with things like drug abuse,” he said “It’s particularly frustrating, of course, because hepatitis C is something that we can treat in our patients, particularly if they don’t have advanced liver disease, and they can do quite well if we can just get them treated.”
Engagement
James said the alliance found that patients were not adequately informed about the potential effects of that COVID-19 could have on viral hepatitis care at the start of the pandemic.
“Many people had questions about how COVID-19 might impact them, which are going unanswered. Only 30% of the responders to the WHA survey reported that adequate information had been given about COVID-19 to people living with viral hepatitis,” James said. “Hepatitis is often overlooked on the heath agenda and the people with viral hepatitis, forgotten.”
According to Wilder, Duke University created a protocol in which it partnered with pharmacists to check in on patients after they began hepatitis treatment to alleviate patients’ concerns.
“Engaging the patients more directly in the treatment process to identify issues with compliance — which is very rare — or any issues with tolerance — also very rare — but certainly just ensuring that patients are doing fine and not having issues is helpful during a pandemic,” Wilder said.
Susanna Naggie, MD, associate professor of medicine at Duke University School of Medicine, said there has not been as much outreach to people with viral hepatitis or liver disease during the pandemic as there has been for patients with diabetes and hypertension.
“It’s been more of the one-on-one with my patients who I see every week, making sure they understand the risk of COVID to their overall health regardless of any underlying liver disease, making sure they understand the recommendations by public health officials, making sure they follow those and answer questions they may have,” Naggie said.
Naggie stressed the importance of outreach across all patient groups with chronic medical conditions to ensure they understand recommendations and dispel myths surrounding these recommendations. She said it is important to have a conversation with patients about getting vaccinated.
Beyond COVID-19
Naggie said she saw a “significant dip” in the initiation of direct-acting antiviral treatment related the pandemic, which is critical to elimination efforts.
“I think once we realized this was not going to be a short-term issue, many clinics, including ours, realized that we need to get back to business,” Naggie said. “We’ve been treating people for months, probably dating back into the late summer, early fall, when we realized we need to figure out how to do this differently.”
The pandemic has forced physicians to simplify their approaches to treatment for patients whom they feel confident will take their medications, Naggie said. She highlighted the use of minimal monitoring (“minmon”) to simplify treatment approaches.
At The Liver Meeting Digital Experience, Sunil Solomon, MBBS, PhD, MPH, an associate professor of medicine at Johns Hopkins Medicine, presented results of a “minmon” study in which patients who received a full regimen for HCV and were remotely monitored achieved 95% SVR.
According to Naggie, the change in practice necessitated by COVID-19 that has made clinicians limit in-person visits and, in some cases, lab visits, may make it easier for patients to go through treatment in the long term and would be aligned with recent clinical trials supporting minimal monitoring approaches.
James reported that various liver organizations made a call to action in November 2019 to explore ways to decentralize hepatitis prevention, testing and treatment services.
“This pandemic is an opportunity to accelerate this call to action; however, many civil society organizations face an uncertain future,” James said.
Wilder said that WHO may adjust plans regarding timing goals because of the burden of the COVID-19 pandemic, although WHO has not proposed a revision date.
“The elimination of hepatitis needs to become a priority for countries. With less than 10 years to go to the 2030 elimination targets, countries cannot afford to wait for the COVID-19 pandemic to end to act on hepatitis,” James said. “All avenues to accelerate hepatitis elimination need to be explored. This includes repurposing COVID-19 testing capacity for hepatitis screening in the future and exploring how lessons learned from COVID-19 could be applicable to the global hepatitis response.”
- References:
- Kaufman HW, et al. Am J Prev Med. 2021;doi:10.1016/j.amepre.2021.03.011.
- Laury J, et al. Clin Liver Dis. 2021;doi:10.1002/cld.1088.
- Solomon S. Late-breaking oral session 2. Presented at: The Liver Meeting Digital Experience; November 13-16, 2020 (virtual meeting).
- WHO. Global progress report on HIV, viral hepatitis and sexually transmitted infections, 2021. https://www.who.int/publications/i/item/9789240027077. Accessed August 2, 2021.
- Wingrove C, et al. Lancet Gastroenterol Hepatol. 2020;doi:10.1016/S2468-1253(20)30238-7.
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