Diagnóstico tradicional versus diagnóstico en un solo paso del virus de la hepatitis C. Estudio piloto en 2 centros asistenciales

Reflex Hepatitis C Virus Viral Load Testing Following an Initial Positive Hepatitis C Virus Antibody Test: A Global Systematic Review and Meta-analysis

BACKGROUND

Many people who have a positive hepatitis C virus (HCV) antibody (Ab) test never receive a confirmatory HCV RNA viral load (VL) test. Reflex VL testing may help address this problem. We undertook a systematic review to evaluate the effectiveness of reflex VL testing compared with standard nonreflex approaches on outcomes across the HCV care cascade.

METHODS

We searched 4 databases for studies that examined laboratory-based reflex or clinic-based reflex VL testing approaches, with or without a nonreflex comparator, and had data on the uptake of HCV RNA VL test and treatment initiation and turnaround time between Ab and VL testing. Both laboratory- and clinic-based reflex VL testing involve only a single clinic visit. Summary estimates were calculated using random-effects meta-analyses.

RESULTS

Fifty-one studies were included (32 laboratory-based and 19 clinic-based reflex VL testing). Laboratory-based reflex VL testing increased HCV VL test uptake versus nonreflex testing (RR: 1.35; 95% CI: 1.16-1.58) and may improve linkage to care among people with a positive HCV RNA test (RR: 1.47; 95% CI: .81-2.67) and HCV treatment initiation (RR: 1.03; 95% CI: .46-2.32). The median time between Ab and VL test was <1 day for all laboratory-based reflex studies and 0-5 days for 13 clinic-based reflex testing.

CONCLUSIONS

Laboratory-based and clinic-based HCV reflex VL testing increased uptake and reduced time to HCV VL testing and may increase HCV linkage to care. The World Health Organization now recommends reflex VL testing as an additional strategy to promote access to HCV VL testing and treatment.

CLINICAL TRIALS REGISTRATION

PROSPERO CRD42021283822.

Generalized implementation of reflex testing of hepatitis C in Galicia: Results for reflection

INTRODUCTION

The implementation of reflex testing of active hepatitis C virus (HCV) infection, together with the incorporation of informative alerts in the reports, has shown that it significantly reduces the number of patients who were not referred for therapeutic evaluation.

METHODS

Since the implementation in 2018 of the DUSP in the Microbiology Services of the Galician Health Service hospitals (SERGAS), new diagnoses of active HCV infection have been retrospectively identified and characterized.

RESULTS

In 2018, a total of 258 patients with unknown active HCV infection (70,2% men, middle age 52 years) were identified through by reflex testing from consultations of primary and specialized care units in 54.8% and 39.8% respectively, as well as from other locations by 5.4%. Of the 258 patients, 81.0% were referred for therapeutic evaluation, with a median of 54 days from their diagnosis. In 58.3% of the cases the reflex testing was determined by viral load, the predominant genotype was 1a (30,7%) and 52,1% were treated, observing sustained viral response (SVR) in 93.7 % of these.

CONCLUSION

The generalized implementation of the HCV reflex testing together with informative alerts in Galicia has allowed us to obtain referral rates for treatment similar to those obtained in other studies. However, there is a wide variability between the different centers that require the incorporation of improvements, such as training or the use of rescue measures for optimization.

Current position of viral load versus hepatitis C core antigen testing

Quantification of hepatitis C virus (HCV) RNA (viral load) is the most widely used marker to diagnose and confirm active HCV infection. The HCV core antigen forms part of the internal structure of the virus and, like HCV RNA, its detection also indicates viral replication and presents certain advantages over viral load testing such as its lower cost, the greater stability of the target, the possibility of working with the same primary tube as that used for HCV serology, and the rapidity of obtaining results, since there is no need to work in batches, unlike the situation with most viral load platforms. Although the core antigen has lower analytical sensitivity than HCV RNA for the detection of low viremia levels, several studies and guidelines have already shown their utility in the identification of patients with active HCV infection. This article summarises current platforms for viral load determination, including point-of-care systems, and also reviews the indications attributed to this marker by the main HCV treatment guidelines. The article also reviews the characteristics of HCV core antigen, the available platforms for its determination, its correlation with viral load determination, and the indications for this marker in the distinct guidelines.

Active search for hepatitis C patients in Primary Care

INTRODUCTION

Undiagnosed hepatitis C virus (HCV) active infections pose a problem to achieve the WHO (World Health Organization) hepatitis C elimination goal in 2030. One of the possible strategies to identify these patients is the active search for patients in Primary Care (PC).

METHODS

We reviewed patient´s medical record in PC with a "hepatitis C" open case in the last five years. We included those with uncompleted diagnostic study - due to the absence of active infection confirmation -, or those who did not start or finish treatment. A blood analysis was recommended to prove the existence of the active infection. The one-step diagnosis (OSD) was implemented to assess the viremia in all patients with a new serologic diagnosis.

RESULTS

Of 253 cases with a "hepatitis C" open case in their medical records, 24.1% (61) did not finished the diagnostic study or did not follow the treatment. Four of them were not suitable candidates to finish the study. Of the other 57, 92.9% accepted diagnostic test. Active infections were confirmed in 40 patients (75.4%) and the treatment was completed in all of them.

CONCLUSIONS

Active search for patients with hepatitis C in PC together with the OSD are effective measures to detect hidden infections and to increase the number of treatments, contributing to the elimination of hepatitis C.

Generalized implementation of reflex testing of hepatitis C in Galicia: Results for reflection

INTRODUCTION

The implementation of reflex testing of active hepatitis C virus (HCV) infection, together with the incorporation of informative alerts in the reports, has shown that it significantly reduces the number of patients who were not referred for therapeutic evaluation.

METHODS

Since the implementation in 2018 of the DUSP in the microbiology services of the Galician Health Service hospitals (SERGAS), new diagnoses of active HCV infection have been retrospectively identified and characterized.

RESULTS

In 2018, a total of 258 patients with unknown active HCV infection (70,2% men, middle age 52 years) were identified through by reflex testing from consultations of primary and specialized care units in 54.8% and 39.8% respectively, as well as from other locations by 5.4%. Of the 258 patients, 81.0% were referred for therapeutic evaluation, with a median of 54 days from their diagnosis. In 58.3% of the cases the reflex testing was determined by viral load, the predominant genotype was 1a (30,7%) and 52,1% were treated, observing sustained viral response in 93.7% of these.

CONCLUSION

The generalized implementation of the HCV reflex testing together with informative alerts in Galicia has allowed us to obtain referral rates for treatment similar to those obtained in other studies. However, there is a wide variability between the different centers that require the incorporation of improvements, such as training or the use of rescue measures for optimization.

Electronic medical record alert activation increase hepatitis C and HIV screening rates in primary care practices within a large healthcare system

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The electronic medical record alert improved screening for HCV and HIV.

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91% of HCV and 100% of HIV positive patients were linked into care.

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Low post-intervention screening rates suggest additional interventions are required.

Societal and economic burdens of hepatitis C virus (HCV) and human immunodeficiency virus (HIV) continue to grow. The Centers for Disease Control and Prevention recommends a one-time HCV screen for individuals in the Baby Boomer population (those born between 1945 and 1965) and a one-time HIV screen for all individuals between ages 13–64 years regardless of risk factors, with more frequent screening for both conditions based on individual risk factors.

This study took place at Atrium Health, a healthcare system with approximately 12 million patient encounters per year. The aims of this study were to assess the impact of the HCV and HIV electronic medical record (EMR) alerts recently implemented on screening rates and linkage to care.

Data were collected from 12 primary care practices. Implementation of EMR alerts increased HCV and HIV screening from 1,934 of 59,632 (3.2%) to 13,726 of 60,422 (22.7%) and 6,950 of 112,813 (6.2%) to 12,379 of 109,173 (11.3%) respectively. The HCV screening resulted in an increase of patients with antibody positive results having a subsequent RNA test from 68% (122/179) to 98% (430/442). 74 of 81 (91%) of HCV and 15 of 15 (100%) of HIV positive patients were linked into care.

The addition of an EMR alert was associated with improved screening for HCV and HIV in primary care practices. Screening all patients decreases testing stigma since there is a lowered risk of disease transmission for those who test positive. However, post-intervention screening rates indicate further opportunities exist for additional interventions to increase screening rates.

Prevalence of HCV infection in a health area of Madrid (Spain): The first step towards microelimination

OBJECTIVE

To estimate the prevalence of HCV infection in the general population of a health area through an intervention in Primary Care, differentiating between new diagnoses and infections previously diagnosed but not treated.

METHODS

Participants were selected through a risk assessment questionnaire, with all those who gave at least one affirmative answer and all those over 50 years of age undergoing a rapid test. Positive tests were confirmed in the lab by determination of anti-HCV antibodies by chemiluminescent microparticle immunoassay and determination of viraemia.

RESULTS

Of the 7,991 participants, 36.2% presented a positive HCV risk questionnaire. 4,717 tests were performed, finding an anti-HCV percentage of 0.65% in the screened population, with 0.46% of active infections. Among the individuals with a positive test result, 51.9% had a known prior diagnosis but had not received treatment, because they were not aware of it or were not linked to the health system, and 19.2% had a positive result for the first time. The prevalence of hidden infection was higher in men, those over 50 years of age and people from Eastern Europe.

CONCLUSION

We found a prevalence of active infections higher than recently described nationwide, and a higher percentage of newly diagnosed infections than recent similar studies in other areas. These differences justify the need to perform local assessments of the prevalence of HCV infection in each of the health areas where it is planned to implement and monitor a microelimination programme.