Impact of the COVID-19 pandemic on HCV elimination in Spain
Authors: Maria Buti, Raquel Domínguez-Hernández, Miguel Angel Casado
Journal: Journal of Hepatology (2020)

Impact of COVID-19 on global HCV elimination effortsJournal of HepatologyVol. 74Issue 1PreviewCoronavirus disease 2019 (COVID-19) has placed a significant strain on national healthcare systems at a critical moment in the context of hepatitis elimination. Mathematical models can be used to evaluate the possible impact of programmatic delays on hepatitis disease burden. The objective of this analysis was to evaluate the incremental change in HCV liver-related deaths and liver cancer, following a 3-month, 6-month, or 1-year hiatus in hepatitis elimination programs. Full-Text PDF We read with great interest the article by Sarah Blach and coworkers1Blach S. Kondili L.A. Aghemo A. Cai Z. Dugan E. Estes C. et al.Impact of COVID-19 on global HCV elimination efforts.J Hepatol. 2021; 74: 31-36Abstract Full Text Full Text PDF PubMed Scopus (185) Google Scholar investigating the impact of COVID-19 on global hepatitis C elimination efforts. The authors show that over the next 10 years a 1-year delay scenario related to COVID-19 would result in 44,800 excess hepatocellular carcinoma (HCC) cases globally and 72,300 excess liver-related deaths, relative to a no delay scenario. The excess HCC cases and deaths would be among high-income countries.1Blach S. Kondili L.A. Aghemo A. Cai Z. Dugan E. Estes C. et al.Impact of COVID-19 on global HCV elimination efforts.J Hepatol. 2021; 74: 31-36Abstract Full Text Full Text PDF PubMed Scopus (185) Google Scholar Spain is one of the 45 high-income countries on the right track to reach HCV elimination by 2030 if the current screening and therapy rates are maintained.2Razavi H. Pawlotsky J.M. Lazarus J.V. Feld J. Bao Y. Pires dos Santos A.G. et al.Global timing of hepatitis C virus elimination in high-income countries: an updated analysis.in: Poster presented in The Digital International Liver Congress. 2020Abstract Full Text PDF Google Scholar However, COVID-19 strongly hit the country in March 2020 and continues to date. The first wave from March to June prompted a country-wide lockdown and the second wave has been ongoing since September. During this overall period, there has been a drop in HCV testing, linkage to care, harm reduction programs, and microelimination programs.3Picchio C.A. Valencia J. Doran J. Swan T. Pastor M. Martró E. et al.The impact of the COVID-19 pandemic on harm reduction services in Spain.Harm Reduct J. 2020; 17: 87Crossref PubMed Scopus (33) Google Scholar We aimed to assess the impact of COVID-19 on hepatitis C elimination in Spain. A previously validated Markov model4Turnes J. Domínguez-Hernández R. Casado M.Á. Cost-effectiveness analysis of two treatment strategies for chronic hepatitis C before and after access to direct-acting antivirals in Spain.Gastroenterol Hepatol. 2017; 40: 433-446Crossref PubMed Scopus (13) Google Scholar was adapted to simulate the effect of pandemic-related delays in HCV diagnosis and treatment on future advanced liver-related disease and deaths in the next 10 years. We used the data obtained to evaluate repercussions on the WHO goals by 2030 and to calculate the economic impact regarding healthcare costs (€, 2020). A cohort of 15,859 patients was analysed comparing two scenarios: the non-COVID-19 scenario, where all patients would be diagnosed and treated in the first year, 2020, and the COVID-19 scenario where there would be an 18-month delay from the beginning of 2020 to the end of June 2021 with a view to the expected vaccine availability in mid-2021. The simulation used clinical data from patients with HCV treated with direct-acting antivirals in Spain (January 2019 to August 2020).5Plan Estratégico para el abordaje de la Hepatitis C en el SNS (PEAHC)Ministerio de Sanidad, Consumo y Bienestar Social.October 2020https://www.mscbs.gob.es/ciudadanos/enfLesiones/enfTransmisibles/hepatitisC/PlanEstrategicoHEPATITISC/docs/Plan_Estrategico_Abordaje_Hepatitis_C_(PEAHC).pdfGoogle Scholar In the COVID-19 scenario, the number of monthly HCV treatments decreased by between 19% and 84%5Plan Estratégico para el abordaje de la Hepatitis C en el SNS (PEAHC)Ministerio de Sanidad, Consumo y Bienestar Social.October 2020https://www.mscbs.gob.es/ciudadanos/enfLesiones/enfTransmisibles/hepatitisC/PlanEstrategicoHEPATITISC/docs/Plan_Estrategico_Abordaje_Hepatitis_C_(PEAHC).pdfGoogle Scholar from early 2020 to June 2021. In addition, it was assumed that patients would be treated in the following year and a half (50% from July 2021 and 50% during 2022), based on the 2019 distribution of patients. Patients with a delay in diagnosis and treatment progressed according to the natural course of the disease. Cohort baseline characteristics (average age and fibrosis) and sustained virological response were taken from published real-world data in Spain.5Plan Estratégico para el abordaje de la Hepatitis C en el SNS (PEAHC)Ministerio de Sanidad, Consumo y Bienestar Social.October 2020https://www.mscbs.gob.es/ciudadanos/enfLesiones/enfTransmisibles/hepatitisC/PlanEstrategicoHEPATITISC/docs/Plan_Estrategico_Abordaje_Hepatitis_C_(PEAHC).pdfGoogle Scholar Fig. 1 shows the results for both scenarios by 2030. An 18-month delay in HCV diagnosis and treatment due to the COVID pandemic in a cohort of 15,859 patients would increase the number of liver-related deaths, HCC, and HCV-related decompensated cirrhosis by 117, 73, and 118 cases, respectively. In economic terms this would translate into a 1.0 M€ cost increase due to decompensated cirrhosis and a 1.3 M€ increase due to HCC. Furthermore, a high number of patients (34 vs. 48) would need a liver transplant due to decompensated cirrhosis or HCC. The cost associated with liver transplantation would increase by 2.5 M€ (5.8 vs. 8.3) for the total cohort during this period. The data derived here are based on a simulation with 15,859 patients, but it is estimated that 76,839 people still have active HCV infection in Spain.6Grupo de trabajo del estudio de prevalencia de la infección por hepatitis C en población general en España; 2017-2018Resultados del 2º Estudio de Seroprevalencia en España (2017-2018). Ministerio de Sanidad, Consumo y Bienestar Social.2019https://www.mscbs.gob.es/ciudadanos/enfLesiones/enfTransmisibles/sida/docs/INFORME_INFECCION_VHC_ESPANA2019.pdfGoogle Scholar Thus, if a larger number of patients is affected by the COVID-19 pandemic, the actual clinical and economic impact would be greater. The data we report were estimated with a different methodology than that used by Blach1Blach S. Kondili L.A. Aghemo A. Cai Z. Dugan E. Estes C. et al.Impact of COVID-19 on global HCV elimination efforts.J Hepatol. 2021; 74: 31-36Abstract Full Text Full Text PDF PubMed Scopus (185) Google Scholar in her study on the global impact of COVID-19 on hepatitis C elimination. Nonetheless, the findings are similar: delaying HCV elimination programs will be associated with an increase in HCV-related morbidity and mortality in the next 10 years. Spain was on track for HCV elimination, but the COVID-19 pandemic has hindered efforts to maintain the cascade of care for HCV and many microelimination programs.7Guía de cribado de la infección por el VHC. Ministerio de Sanidad, Consumo y Bienestar Social. Available in: https://www.mscbs.gob.es/ciudadanos/enfLesiones/enfTransmisibles/sida/docs/GUIA_DE_CRIBADO_DE_LA_INFECCION_POR_EL_VHC_2020.pdf.Google Scholar The excess morbidity and mortality caused by this delay calls for the reinforcement of screening programs, particularly in vulnerable populations and those with more difficult access to primary care physicians.8WHOGlobal health sector strategy on viral hepatitis 2016–2021, Towards ending viral hepatitis. World Health Organization June, Geneva, Switzerland2016Google Scholar This will be possible if the EASL guidelines for hepatitis C are applied.9Boettler T. Marjot T. Newsome P.N. Mondelli M.U. Maticic M. Cordero E. et al.Impact of COVID-19 on the care of patients with liver disease: EASL-ESCMID position paper after 6 months of the pandemic.JHEP Rep. 2020; 2: 100169Abstract Full Text Full Text PDF PubMed Scopus (116) Google Scholar In summary, hepatitis C elimination must continue to be a political goal and a priority of our health system. The implementation of telehealth, home-delivery services for drugs or HCV screening when COVID tests are performed could minimize the impact of the COVID pandemic on HCV patients and HCV elimination. MB none. PORIB has received unconditional funding from Gilead Sciences, Spain for this analysis. All authors contributed equally to the concept and design, to the preparation of the manuscript and read and approved the final manuscript. RDH performed the modelling analyses. MB: Advisory Board participant for Gilead and Abbvie. RDH and MAC are employees of Pharmacoeconomics & Outcomes Research Iberia, a consultancy firm specialising in the economic evaluation of healthcare interventions that has received unconditional funding from Gilead Sciences. Please refer to the accompanying ICMJE disclosure forms for further details. The following is the supplementary data to this article: Download .pdf (.25 MB) Help with pdf files Multimedia component 1