Patients with hepatitis C lost to follow-up: ethical-legal aspects and search results

Recommendations for the integral diagnosis of chronic viral hepatitis in a single analytical extraction

The Spanish Society of Digestive Pathology (SEPD), the Spanish Association for the Study of the Liver (AEEH), the Spanish Society of Infections and Clinical Microbiology (SEIMC) and its Viral Hepatitis Study Group (GEHEP), and with the endorsement of the Alliance for the Elimination of Viral Hepatitis in Spain (AEHVE), have agreed on a document to carry out a comprehensive diagnosis of viral hepatitis (B, C and D), from a single blood sample; that is, a comprehensive diagnosis, in the hospital and/or at the point of care of the patient. We propose an algorithm, so that the positive result in a viral hepatitis serology (B, C and D), as well as human immunodeficiency virus (HIV), would trigger the analysis of the rest of the virus, including the viral load when necessary, in the same blood draw. In addition, we make two additional recommendations. First, the need to rule out a previous hepatitis A virus (VHA) infection, to proceed with its vaccination in cases where IgG-type studies against this virus are negative and the vaccine is indicated. Second, the determination of the HIV serology. Finally, in case of a positive result for any of the viruses analyzed, there must be an automated alerts and initiate epidemiological monitoring.

Retrieval and treatment of patients with primary biliary cholangitis who are lost in the health system

INTRODUCTION

hepatitis C patients loss to follow-up in the health care system has been shown to have negative consequences. This study aimed to investigate this issue as regards primary biliary cholangitis.

METHODS

the databases (immunology, biochemistry, clinical reports, drug dispensation, appointments) of 4 reference hospitals in Spain (serving a population of 1,450,000 inhabitants) were analyzed. The diagnosis of primary biliary cholangitis was based on an antimitochondrial antibody titer ≥ 1:80, chronically elevated alkaline phosphatase, and the absence of other liver disease. Patients were classified as lost in the absence of reports indicating a diagnosis, specific medical follow-up, and/or treatment with bile salts.

RESULTS

a total of 1372 patients with antimitochondrial antibody titers ≥ 1:80 were included between January 2010 and June 2019. A total of 697 (50.8 %) were classified as having primary biliary cholangitis, and 100 patients (14.3 %; 95 % CI: 11.8-17.2) were identified as lost. Of these, 30 were contacted and retrieved. The median age was 70 years, 93 % were female, median alkaline phosphatase was 185 IU/L, 10 % had pruritus, and 27 % had a transient elastography value > 9.5 kPa. The disease was confirmed and ursodeoxycholic acid was started in all 30 patients. Death was liver-related in 6 of the 100 patients classified as lost.

CONCLUSION

up to 14.3 % of patients (1 out of 7) with a definitive diagnosis of primary biliary cholangitis remain undiagnosed, thus preventing monitoring and treatment. More than a quarter are at risk of advanced liver disease and its complications. Patients lost in the system must be identified and retrieved, and searching hospital databases is a suitable approach to meet this goal.

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.

The Screening Guidelines for Hepatitis C Virus Infection as a milestone in the path towards hepatitis C virus elimination

The publication of the Screening Guidelines for Hepatitis C Virus Infection represents a significant milestone in the path towards eliminating this infectious condition. As early as 2015, the National Health System Plan for Tackling Hepatits C (Plan estratégico para el abordaje de la hepatitis C - PEAHC) pointed out the need to define a screening policy. The Health Ministry has managed to bring together all the actors involved, and to create a technical document that represents a benchmark in the definition of the actions needed to identify and bring treatment closer to a significant number of patients diagnosed with hepatitis C who remain untreated.

CHRONIC HEPATITIS C PATIENTS LOST IN THE SYSTEM: PREDICTIVE FACTORS OF NON-REFERRAL OR LOSS OF FOLLOW UP TO HEPATOLOGY UNITS

INTRODUCTION

Several barriers remain in the hepatitis C care cascade, which need to be removed in order to eliminate Chronic Hepatitis C. These barriers include deficiencies in screening and confirmatory diagnosis as well as difficulties in accessing treatment.

AIMS

To identify factors associated with the non-referral of patients with positive HCV-antibody and to identify factors associated with loss of follow-up or non-attendance of these patients to specialist consultation after their referral.

METHODS

Observational and retrospective single-centre-study, including all positive HCV serologies performed between January 2013 and May 2018 in the Virgen Macarena health area before implementing the one-step diagnosis. Non-referred patients and patients who were lost to follow-up after being referred were identified.

RESULTS

A total of 54 (77.4%) patients diagnosed in PC and 54 (22.2%) from hospital specialists were not referred (p <0.001). Predictors for non-referral were: stay in prison/ institutionalized (p = 0.04), suffering COPD (p = 0.07), a normal AST value (p = 0.034) or test requested by PCP (p = 0.004). Patients referred from PC were more likely to be lost to follow-up than those referred from hospital specialists (p <0.001). Predictors for loss of follow-up included: opioid replacement therapy (p = 0.034), absence of high blood pressure (p = 0.039) and test requested by PCP (p = 0.049).

CONCLUSIONS

A high percentage of patients with positive HCV serology were not referred or lost follow-up, mainly those belonging to high risk social groups or those with associated comorbidities. Patients with average values of transaminases or those diagnosed in primary care were also less referred.