COVID-19 impacts the global 2030 target to eliminate viral hepatitis
Prior to the COVID-19 pandemic, WHO set a target to eliminate viral hepatitis around the world by 2030. But, as focus necessarily turned toward the pandemic, the organization seems to now doubt viral hepatitis elimination goals will be met.
The World Hepatitis Alliance (WHA), which represents 300 member organizations from 99 countries, assessed the impact of COVID-19 on WHO’s goal through a survey. Between March 30, 2020, and May 4, 2020, 132 self-selecting individuals from 32 countries responded to the survey, and WHA published the results in Lancet Gastroenterology and Hepatology.
Most responders (n = 123) reported their services were impacted by the COVID-19 crisis. Only 47 responders said they had access to viral hepatitis testing. Reports from 101 respondents showed closure of testing facilities as the main reason for lack of access to testing.
Of the 68 respondents outside the U.S., 23 reported patients who need hepatitis treatment were not able to access medication.
“Only five (8%) of 64 respondents from the USA reported that people living with viral hepatitis were unable to access treatment during the pandemic,” Chris Wingrove, from the WHA, and colleagues wrote. “Inability to access 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,” 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 added, “Hepatitis community organizations can test for both COVID-19 and viral hepatitis in settings that are already trusted by their communities. From this crisis, we have an opportunity to evolve health systems to better serve us all. Hepatitis elimination must not be left behind.”
The Coalition for Global Hepatitis Elimination (CGHE) also sent a survey to clinicians and program managers to assess mitigation strategies to decrease transmission and changes to hepatitis treatment and access to hepatitis testing. It published results in Clinical Liver Disease. Respondents included 103 clinicians and program managers from 44 countries comprising six WHO regions.
The 53-question survey covered hepatitis B virus and hepatitis C virus services delivered prior to the emergence of COVID-19, during the months impacted by COVID-19, and the month of survey completion; and mitigation strategies.
“The response to COVID-19 precipitated a large decline in infant immunization protecting children from infection and liver cancer in later life,” John W. Ward, MD, from the CGHE Task Force for Global Health in Decatur, Georgia, and colleagues wrote. “WHO estimated an additional 5 million infections resulting from the loss of immunization. By summer 2020, the U.S. immunization coverage declined approximately 40% from the previous year. By summer 2020, states and cities in the United States were reporting up to 40% declines in infant immunization coverage from the previous year.”
Ward and colleagues wrote that the survey showed the COVID-19 pandemic did decrease hepatitis prevention, testing and treatment. In the immediate term, they postulated this slowed or stopped progress toward goals for hepatitis elimination.
In an interview with Healio Gastroenterology, Ward said mitigation strategies to stop transmission aids clinicians to safely overcome the decrease in hepatitis care during the COVID-19 response. The hepatitis community can safely continue to deliver services and help programs to initiate mitigation strategies. Ward and colleagues said this should be used as a learning opportunity to initiate change in clinical care to advance progression toward hepatitis elimination.
“Fortunately, 75% of clinicians report increased testing and treatment as health systems adopt new strategies to maintain patient care,” Ward told Healio Gastroenterology.
Cary James, CEO of WHA, told Healio that COVID-19 has drastically impacted hepatitis elimination efforts globally. Hepatitis prevention, testing and treatment services have significantly decreased, and, in some countries, they have been ceased entirely.
“The majority of countries were not on track to reach WHO’s goal of eliminating viral hepatitis by 2030 and the pandemic has meant that many countries will fall further behind,” James said. “With the uncertain global financial outlook created by the pandemic, it is likely that countries will begin looking to reassess their health expenditure.”
According to James, this means countries may decrease funding for hepatitis programs, but this should not be allowed to happen he said. Countries should be supported to both increase hepatitis programs and reach the goal to eliminate hepatitis globally.
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 UN general assembly to assess impact of COVID-19 and potential opportunities to 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 advantages of improvements in housing for the homeless and other responses to the COVID-19 pandemic to increase access to hepatitis C 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 on-line services, medicines to patient’s homes and essential foods and protective equipment to those who were most vulnerable.
In an interview with Healio Gastroenterology, Julius Wilder, MD, assistant professor of medicine at Duke University, said, “We have seen that the social isolation that comes with COVID has contributed to a number of adverse 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 drive of new hepatitis C diagnoses in the United States.”
Impact From the Pandemic
James noted the WHA found there was not adequate information available on the effect of COVID-19 on people with viral hepatitis 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.
Anna S. Lok, MD, professor of internal medicine and director of clinical hepatology at University of Michigan, said in an interview 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.”
Lok said the elimination of hepatitis relies on public health departments’ finances and resources; therefore, countries around the world have suffered greatly because public health expenditures have been shifted to the pandemic.
Wilder said alcohol abuse has also increased during the pandemic, which has a negative effect on people with liver problems. He said this plus living in areas where they may be barriers to getting care led to the “perfect storm for delayed care and negative outcomes in our patients with any chronic liver disease, but particularly hepatitis C.”
Access to Care
James noted the mixed results regarding access to medications.
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,” James said.
One positive during the COVID-19 pandemic according to James 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 which continues,” James said.
Lok 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. She said although these patients have turned to telemedicine, it does not work for everyone.
Lok was able to provide her patients some sort of care through virtual visits and convinced many to complete their lab work done.
“We have patients even now who absolutely have missed getting tested for almost a year, and I just cannot convince them,” Lok said.
Providing current information about COVID-19 to patients with liver disease is important, Ward said. Some ways for patients to stay up to date include communication-based organizations with constituents at an increased risk for hepatitis and COVID-19.
Wilder said Duke University created a protocol where they partnered with pharmacists and 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,” Susanna Naggie, MD, associate professor of medicine at Duke University School of Medicine, told Healio.
Naggie said there has not been much outreach to people with hepatitis C, viral hepatitis or liver disease. While there is a focus on diabetes and hypertension, she said there is not enough focus on liver disease.
“It’s been more of the one-on-one with my patients that I see every week, making sure they understand the risk of COVID to their overall health regardless of any underlying liver disease, make 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. Now that COVID-19 vaccinations are rolling out, she said it is important to have a conversation with patients about getting vaccinated.
Wilder and colleauges implemented a telemedicine infrastructure to offer insight on health issues that are COVID-19 specific and may be patient-facing.
“Entities like AASLD have done a good job of creating physician-facing information around this, but we all need to do a better job of creating more patient-facing information and partnering with our various patient advocacy groups with hepatitis C so that we can work with them around this,” Wilder said.
Looking Beyond COVID-19
Naggie said with COVID-19 there was a significant decrease in direct-acting antiviral treatment statistics and yet treatment is critical to the elimination efforts.
The pandemic has forced physicians to simplify their approaches to treatment for patients whom they feel confident will take their medications, according to Naggie.
She highlighted the use of minimal monitoring to simplify treatment approached. At The Liver Meeting Digital Experience, Sunil S. Solomon, PhD, MPH, MBBS, from Johns Hopkins, presented the minimal monitoring – or “Minmon” – study, where patients are given a full regimen for hepatitis C virus and remotely monitored. Patients achieved 95% sustained virologic response.
Sunil noted this study was made for COVID-19, as it minimized contact and increase the use of remote approaches.
COVID-19 has made clinicians change their practice, limiting in-person visits and in some cases lab visits, Naggie said. In the long-term this may make it easier for patients to go through treatment and would be aligned with recent clinical trials supporting minimal monitoring approaches.
“Throughout the pandemic, WHA has championed the important role of civil society organizations in protecting their communities against hepatitis and COVID-19,” James said. “We have shown that civil society has a central role to play in the pandemic response.”
James reported that EASL, AASLD, APASL and ALEH 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 the WHO may adjust plans in terms of timing goals due to the burden of the COVID-19 pandemic. Although the WHO has not proposed a revision date, according to Ward. Ward noted the U.S. HHS released a national plan with 2030 goals.
“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 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.”
- Jessica L, et al. Clin Liver Dis (Hoboken). 2021;doi:10.1002/cld.1088.
- Healio. https://www.healio.com/news/hepatology/20201117/minimal-monitoring-program-achieves-svr-in-hepatitis-c. Accessed: April 19, 2021.
- Solomon SS. Late-breaking Oral Session 2. Presented at: The Liver Meeting Digital Experience; November 13-16, 2020.
- Wingrove C, et al. Lancet Gastroenterol Hepatol. 2020;doi:10.1016/S2468-1253(20)30238-7.