Let’s leverage SARS-CoV2 vaccination to screen for hepatitis C in Spain, in Europe, around the world

To the Editor:

Since 2015, Spain has had a national strategic plan for tackling HCV and has been recognised as one of the best positioned countries in the world for achieving HCV elimination.¹ Its innovative strategies (e.g. one-step diagnosis, alert systems from microbiology laboratories, point-of-care diagnostics and simplified patient care pathways) have substantially decreased the delay between diagnosis and treatment by greatly improving linkage to care through more patient-centred approaches. At the start of 2020, HCV elimination appeared to be within grasp, but the COVID-19 pandemic has derailed this progress in Spain and the rest of the world.² In addition, the SARS-CoV-2 infection has exacerbated heath inequalities³; and many HCV patients are marginalized and thus highly vulnerable.

The real impact of the COVID-19 pandemic remains unknown but HCV programmes, from micro-elimination efforts to larger awareness campaigns, have come to a standstill. We read with interest the article by Blach et al. evaluating the impact of COVID-19 on global HCV elimination efforts.⁴ Based on mathematical modelling, the authors suggest that a 1-year hiatus in HCV elimination programmes could result in 72,300 excess liver-related deaths and 44,800 excess liver cancers globally over the next 10 years. Along this line, Buti et al. have recently modelled the magnitude of the impact in Spain on HCV burden of the delay in its diagnosing and treating, also showing a marked increase in HCV-related morbidity-mortality.⁵ Blach et al. conclude that attention should shift back to hepatitis programming as soon as it becomes safe to do so.⁴ We believe that that time is now and we must and can combat the dual threats of SARS-CoV-2 and HCV infection jointly, as has recently been suggested.⁶

The majority of the European population will be vaccinated against SARS-CoV-2 by the end of 2021. This presents a window of opportunity to combine HCV detection with COVID-19 vaccination efforts and may allow us to hit two targets with one shot: eliminate a slow and deadly epidemic, HCV; and mitigate a fast and deadly pandemic, COVID-19. Thanks to HCV point-of-care tests, in particular dried-blood-spots, this approach does not involve major logistical issues or major additional costs to vaccination campaigns. Indeed, HCV screening strategies have been shown to be cost-effective across all age cohorts.⁷ The 15-20 minutes that patients wait after vaccination is an ideal time to test for HCV. While there are other health conditions that may also warrant linked testing to COVID-19 testing and vaccination, and this should be determined at the local level, we argue that HCV be considered given the world's commitment (assumed by WHO) to eliminating HCV as a public health threat by 2030. Momentum needs to be renewed and given the challenge in reaching both the general population and, particularly, marginalized populations, this is a unique opportunity. The HCV field is uniquely positioned to reach difficult-to reach populations like people who inject drugs and some migrant populations. COVID-19 efforts can leverage the expertise and experience of the hepatitis C community, and this would be a mutually beneficial relationship. It is critical to vaccinate as many people as possible, and reaching vulnerable populations is always challenging but always possible with committed stakeholders involved.

Taking this public health approach into account, and aiming to prevent an increase in the social inequities and delayed HCV elimination, 17 Spanish scientific societies and patient associations, part of the Spanish Alliance for Viral Hepatitis Elimination (AEHVE), have released a position statement calling on Spain to capitalise on this historic opportunity and: i) revitalise HCV management, including diagnosis, referrals and treatment initiation; ii) immediately restart HCV micro-elimination programmes, particularly those devoted to marginalised populations; and iii) offer hepatitis B and C screening to anyone undergoing any SARS-CoV-2 serological diagnosis.⁸ The AEHVE position statement is in alignment with the position paper released by the European Association for the Liver Study and the European Society of Clinical Microbiology and Infectious Diseases.⁹

This ambitious proposition has already borne fruit: in a pilot study in a region of Northern Italy.¹⁰ Giacomelli et al. included rapid HCV screening in 2,505 individuals during a program of mass serological SARS-CoV-2 screening. They detected 72 individuals (2.9%) with HCV antibodies, most of them were unaware of their serostatus. And there is another inspiring example in Cantabria, a region in the north of Spain, where a pioneering initiative will be launched to create a multipurpose population cohort for clinical research, taking advantage of the COVID-19 vaccination campaign. In this cohort, HCV infection will be tested in 50,000 individuals with the support and collaboration of the local political and health authorities. This is a good example of the implementation of public health measures during the pandemic. We must now urgently move from positioning ourselves to taking concrete action to further HCV elimination efforts.

Financial support

This study has no funding source.

Authors’ contributions

All authors contributed equally.

Conflict of interests

All authors have nothing to declare.

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Supplementary data

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