Drops in Hepatitis C Testing, Treatment Spark Concern

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The COVID-19 pandemic has coincided with sharp declines in routine testing for and treatment of hepatitis C virus (HCV) infection, according to the results of a collaborative study between the Centers for Disease Control and Prevention (CDC) and Quest Diagnostics. The authors say an associated increase in rates of transmission, morbidity, and mortality for this otherwise curable disease could result.

Dr Harvey Kaufman

Lead author Harvey W. Kaufman, MD, senior medical director and head of the Health Trends Research Program for Quest Diagnostics, told Medscape Medical News, “There are a lot of patients out there who have skipped care.”

Without treatment, he noted, this disease can progress to cirrhosis, hepatocellular carcinoma, and death.

Transmission is also a concern because the majority of people who have HCV are unaware of their disease and lack symptoms, thereby increasing the risk that they might spread it to others.

The study’s findings were published online May 10 in the American Journal of Preventive Medicine. Investigators compared 12,309,475 HCV antibody test results and 326,603 HCV RNA (confirmatory) test results from the months of January to July for the years 2018, 2019, and 2020.

The decrease in HCV antibody testing during the pandemic period was statistically significant (b = -0.440; 95% CI, -0.580 to -0.310; P< .001). In addition, the number of HCV RNA positive tests declined approximately 62.3% in March 2020 and remained low through July in comparison with the same months in 2018 and 2019, according to the study.

The results raise concerns that people living with undiagnosed HCV, the most commonly reported bloodborne infection in the United States, could develop more advanced disease before their status is confirmed.

Additionally, the volume of dispensed direct-acting antivirals decreased 22.7% in April 2020 compared with averages in April 2018 and 2019 and continued to decrease by 39.6% in May to July 2020 compared with the average for the same months in 2018 and 2019.

Kaufman says the research team has continued to analyze results beyond the study period. They found that a strong rebound in testing had occurred by the end of 2020, although testing has not yet recovered to prepandemic levels.

Such delays in care have been a setback for the World Health Organization’s target for eliminating HCV by 2030, Kaufman said.

“We were marching forward until the pandemic,” he added.

These findings mirror those of another study that showed that in the 3.5 months after March 16, 2020, hospital-wide testing fell by 49.6% and new patient identification fell by 42.1%. Ambulatory-only testing and new patient identification fell by 71.9% and 63.3%, respectively.

Dr Jaideep Behari

Jaideep Behari, MD, PhD, of the Center for Liver Diseases of the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, told Medscape Medical News that in the past few months, he and his colleagues have seen an increase in the number of patients returning for HCV testing and treatment after having delayed such care during the pandemic. There has also been in increase in colonoscopies and endoscopies.

Behari said that because HCV generally progresses slowly, delays in care should not have a substantial effect on outcomes, provided patients present sometime this year.

The bigger worry, he said, is in regard to patients who have been lost to follow-up. These patients may never come back to see their physicians and may miss opportunities for testing.

“The concern is always in populations who are high risk, for instance, injection drug users and other vulnerable populations,” he said. “If there’s a break in the linkage to care and referral at the right time, there’s a likelihood that patient may never go back for testing and, potentially, treatment.”

The CDC recommends routine periodic HCV testing for people of all ages who have risk factors. It recommends one-time testing for adults aged 18 years and older and for all pregnant women during each pregnancy, except in regions where HCV infection rates are less than 0.1%.

Behari said that through the combination of telemedicine, the use of nurse practitioners and physician assistants, and flexible scheduling, appointment times for HCV-related care at his center have been reduced from 2 months in 2020 to 1 week or less now.

An estimated 2.4 million adults live with HCV in the United States. The CDC reported that HCV was the underlying or contributing cause for 15,713 deaths in 2018.

Kaufman and two coauthors are employed by Quest Diagnostics and own stock in the company. Behari has disclosed no relevant financial relationships.

Am J Prev Med. Published online May 10, 2021. Full text

Marcia Frellick is a freelance journalist based in Chicago. She has previously written for the Chicago Tribune and Nurse.com and was an editor at the Chicago Sun-Times, the Cincinnati Enquirer, and the St. Cloud (Minnesota) Times. Follow her on Twitter at @mfrellick.

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