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Screening people admitted to hospital with COVID-19 for hepatitis C or hepatitis B does not lead to detection of a large number of undiagnosed infections and is likely to be of limited use in reducing the number of undiagnosed infections, Spanish researchers have concluded after evaluating screening outcomes in 2020.

Their evaluation findings, published in the journal Gastroenterologia y Hepatologia, show that just three chronic hepatitis C infections were detected among 4662 people with COVID-19 admitted to hospitals in Leon and Burgos in 2020. Two of these were diagnosed in men aged 90 and over, the other in a person who died of COVID-19.

In 2020, Spanish physicians urged that everyone tested for SARS-CoV-2 should also be tested for hepatitis B and C and subsequently recommended testing for viral hepatitis in all people vaccinated against SARS-CoV-2. These screening strategies were proposed in order to support progress towards hepatitis C elimination targets, since both modalities would reach large numbers of people who might otherwise have little contact with health services.

Spanish hospitals began testing people admitted with COVID-19 for hepatitis B and C in March 2020, following recommendations from the Spanish Ministry of Health. Patients were screened for hepatitis B antibodies and surface antigen and hepatitis C antibodies and RNA.

An analysis of COVID-19 admissions and viral hepatitis testing in Burgos and Leon found very low rates of chronic hepatitis B and C infection, perhaps because the median age of those admitted to hospital was 76 years.

In spite of these findings, researchers conclude that hepatitis B testing should be emphasised in people admitted to hospital with COVID-19, to minimise the risk of hepatitis B reactivation due to immunosuppressive treatments used to manage severe COVID-19.

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People with diabetes and those with hazardous alcohol intake were significantly more likely to remain undiagnosed with hepatitis C and present with advanced fibrosis, a large number of people diagnosed with hepatitis C in France has reported.

The study investigators say that people with diabetes and people with high alcohol intake should be targeted for hepatitis C screening in France, in order to achieve hepatitis C elimination goals by 2030.

Late diagnosis with hepatitis C means that people are likely to have advanced liver fibrosis or may already have cirrhosis. People diagnosed at this stage may be less likely to achieve cure of hepatitis C when treated, and if they have developed decompensated cirrhosis before treatment, they remain at risk of further life-threatening liver events even if they are cured.

Diagnosing hepatitis C before progression to late-stage liver disease is a high priority for preventing liver-related deaths and achieving the hepatitis C elimination targets of diagnosing 90% of people with hepatitis C and reducing liver-related deaths by 65% by 2030.

French researchers investigated factors associated with late diagnosis in people with hepatitis C in the national HEPATHER cohort. They looked for late presentation – people who were found to have cirrhosis or stage 3 or 4 fibrosis less than a year after their first evaluation by a liver specialist (referral for treatment was carried out by liver specialist until 2019 in France).

Multivariable analysis showed that late presentation was associated with male sex, age over 45 years, HCV genotype 3 infection, diabetes, current hazardous alcohol use and current abstinence but past hazardous alcohol use. In this study hazardous alcohol use was defined as two drinks a day in women or three drinks a day in men.

To reduce the risk of late presentation for hepatitis C treatment, all people with diabetes should be screened for hepatitis C, they recommend. Impaired liver function in people with diabetes should be a warning signal, they say, and requires investigation.

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People who use drugs were over 50% more likely to acquire hepatitis C between 2004 and 2019 if they spent even a brief period in prison, a prospective study carried out in Montréal, Canada, reports.

Improving harm reduction services in short-stay correctional facilities and exploring alternatives to custodial sentences or remand for people who use drugs might have an impact on hepatitis C infection rates in people who use drugs, the researchers say.

Researchers at the University of Bristol investigated the impact of imprisonment on hepatitis C acquisition in people who use drugs in the Montréal Hepatitis Cohort. Between 2004 and 2019, 712 people were eligible for inclusion in the study and had a median of six study visits.

Just under half (47%) were injecting drugs daily and 33% reported sharing injecting equipment in the previous six months. Twenty-six per cent were receiving opioid substitution therapy.

Thirty-five per cent of participants reported at least one episode of incarceration during the previous two years and the median number of episodes was two. Eleven per cent reported that they had been incarcerated in the previous three months.

After adjusting for demographic factors, homelessness, year and opioid substitution therapy, people who experienced an episode of incarceration of less than two years were 56% more likely to acquire hepatitis C compared to those who were not incarcerated.

Short-term incarceration lasting less than a week or incarceration at a police station (short-term remand) were each independently associated with increases in the risk of hepatitis C of approximately 80%.

The study investigators say that it is unlikely that people who experienced short-term incarceration acquired hepatitis C in prison or on remand. Only ten people in the study population reported that they had injected drugs in prison. Instead, short-term incarceration appears to have a disruptive effect, by creating uncertainty and instability.

Several previous studies have shown that levels of drug use and sharing of injecting equipment increase in the period immediately after release from prison, reflecting financial and psychological stress as well as stigmatisation. Short-term incarceration may also disrupt opioid substitution therapy.

The study investigators recommend that everyone entering short-term incarceration should be screened for substance use and offered opioid substitution therapy where indicated. At release, people who use drugs should be offered harm reduction supplies and linked to services that can provide support.

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Ultra-short treatment courses tailored to a person's pre-treatment viral load deliver lower cure rates than 8-week treatment courses, but failure of ultra-short treatment does not prevent subsequent cure of hepatitis C with a second course of treatment, the STOPHCV1 study has found.

Shortening hepatitis C treatment courses may have advantages for people who have adherence difficulties, although adherence to 8-week treatment courses is good. There is some evidence that treatment courses as short as four to six weeks may cure some people with hepatitis C, but it is unclear what criteria should be used to select people for shorter treatment courses.

The STOPHCV1 study randomised people to durations of short-course treatment of paritaprevir/ombitasvir/dasabuvir determined by their baseline viral loads, or to an 8-week course of treatment. Patients had HCV genotype 1 or 4. People who didn’t achieve a sustained virologic response after the first course of treatment were re-treated. The primary outcome of the study was the proportion cured after first- and second-line treatment.

The study recruited 202 people with no or mild fibrosis, as lack of liver damage improves the chances of cure.

Whereas 91% of those in the fixed-duration study arm achieved a sustained virologic response, only 48% in the ultra-short course arm did so after the first course of treatment. After re-treatment, everyone achieved a sustained virologic response.

The study investigators conclude that “a high proportion of patients can be cured with […] approximately 60% of the licensed duration of first-line therapy of agents used in the trial.” But they also note that cure rates with the ultra-short-course regimen were not high enough to justify using it in people able to adhere to an 8-week treatment course.

They also say that the strategy needs to be tested using pangenotypic regimens to assess whether failure of a first-line regimen that does not contain a protease inhibitor permits successful re-treatment in all cases.

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