Towards the elimination of hepatitis C: implementation of reflex testing in Andalusia

Casas, María de la Paz; García, Fernando; Freyre‐Carrillo, Carolina; Montiel, Natalia; Iglesia, Alberto de la; Viciana, Isabel; Domínguez, Ana; Guillot, Vicente; Muñoz-Losa, Aurora; Cantudo, Purificación; Franco-Álvarez, Francisco; Reguera, J A; Romera, María Angustias; Cabezas, Teresa; Vargas, Julio; Ramírez-Arcos, Mercedes; Guerrero, Inmaculada; García-Navarrete, África; Pérez-Santos, María Jesús; Clavijo, Encarnación; Roldán, Carolina; Guzmán, Antonio; Palanca, Matilde; Torres, Eva; Serrano, Maria del Carmen; Lozano, Marı́a D.; Becerril, Berta; Luzón, Pilar; Galán, María Ángeles; Alados, Juan Carlos; García, Féderico

doi:10.17235/reed.2020.6370/2019

Cited by 7 publications

(12 citation statements)

References 23 publications

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“…Data of our study could only confirm that screening could be useful in different hospital divisions but could not give indications of the real prevalence of active infections due to the lack of confirmation of active infection in 33.8% of patients positive for HCV-Ab. In accordance with this data, studies conducted in different contexts have confirmed the significant loss of patients due to the two steps required for confirmation of an HCV-active infection [ 26 , 27 ]. Reflex testing permits the one-step confirmation of the HCV-active infection in patients unaware of their infection status, and it is strongly suggested in hospital settings [ 27 , 28 ].…”

Section: Discussionsupporting

confidence: 67%

Elimination of Hepatitis C in Southern Italy: A Model of HCV Screening and Linkage to Care among Hospitalized Patients at Different Hospital Divisions

Rosato¹,

Kondili

Nevola³

et al. 2022

Viruses

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Background: Free-of-charge HCV screening in some key populations and in 1969–1989 birth cohorts has been funded in Italy as the first step to diagnosing individuals who are infected but asymptomatic. The aim of this study is to evaluate the feasibility of an opportunistic HCV screening and its linkage to care. Methods: A hospital-based HCV screening was conducted as a routine test for in-patients admitted to the Evangelical Hospital Betania of Naples from January 2020 to May 2021. All consecutive in-patients were screened for the HCV antibody (HCV-Ab) at the time of their admission to the hospital, and those born prior to year 2000 were included in the study. HCV-RNA testing was required for those not previously treated and without antiviral treatment contraindications. For in-patients with an active infection, treatment started soon after hospital admission. Results: Among 12,665 inpatients consecutively screened, 510 (4%) were HCV-Ab positive. The HCV-Ab positivity rate increased with age, reaching the highest prevalence (9.49%) in those born before 1947. Among patients positive for HCV, 118 (23.1%) had been previously treated, 172 (33.9%) had been discharged before being tested for HCV-RNA, and 26 (5.1%) had not been tested for short life expectancy. Of 194 (38% of HCV-Ab+) patients who were tested for HCV-RNA, 91 (46.2%) were HCV-RNA positive. Of patients with active infection, 33 (36%) were admitted to the liver unit with signs of liver damage either not previously diagnosed or diagnosed but unlinked to care for HCV infection. Of the patients positive for HCV-RNA, 87 (95.6%) started treatment; all achieved sustained virological response. Conclusion: HCV active infection has been frequently found in patients with comorbidities admitted in the hospital in Southern Italy. To achieve HCV elimination in Italy, broader screening strategies are required. In addition to screening of the 1969–1989 birth cohort of individuals unaware of their infection status, diagnosis and linkage to care of patients with known liver damage is strictly required. Hospital screening is feasible, but prompt reflex testing for identifying HCV-active infections is necessary to increase diagnosis and subsequent linkage to care.

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Section: Discussionsupporting

confidence: 67%

Elimination of Hepatitis C in Southern Italy: A Model of HCV Screening and Linkage to Care among Hospitalized Patients at Different Hospital Divisions

Rosato¹,

Kondili

Nevola³

et al. 2022

Viruses

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“…Studies in Spain have reported an increased prevalence of HCV vRNA reflex testing in Spanish hospitals after specialty societies advocated for reflex testing and improvement of patient linkage to care after implementation of reflex testing. 14 , 15 Reflex testing has been noted to promote a high percentage of HCV vRNA tests for patients with positive HCV Ab tests in an ED HCV screening program; however, the relative increase in HCV vRNA tests done, the impact on linkage to care, and quantification of time saved were not quantified. 16 The high percentage of HCV vRNA tests done in that study (approaching 98%) is a testament to the thoughtfulness and pre-planning undertaken prior to the implementation of their HCV screening program.…”

Section: Discussionmentioning

confidence: 99%

Hepatitis C Virus Reflex Testing Protocol in an Emergency Department

Manteuffel

Lee

Bussa

et al. 2022

WestJEM

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Introduction: Our aim was to measure hepatitis C virus (HCV) screening and linkage-to-care rates in an urban emergency department (ED) before and after implementing an HCV viral RNA (vRNA) reflex testing protocol within a HCV screening program for at-risk patients. Our hypothesis was that using a reflex testing protocol would increase HCV testing rates of at-risk patients in the ED, which would increase the linkage-to-care rate. Methods: In August 2018, our institution implemented an automated, electronic health record-based HCV screening protocol in the ED for at-risk patients. In January 2019, we implemented an HCV vRNA reflex testing protocol (reflex testing) for all positive HCV antibody (Ab) tests that were initiated through the screening protocol. We compared completion rates of HCV vRNA testing and the rate of linkage to care for patients with positive HCV Ab test results before and after implementation of reflex testing (five months per study period). Results: Prior to reflex testing implementation, 233/425 (55%) patients with a positive HCV Ab test had an HCV vRNA test performed, whereas 270/323 (84%) patients with a positive HCV Ab test result had vRNA testing after reflex testing implementation (odds ratio [OR], 4.2; 95% confidence interval (CI): 3.0-6.0; P < 0.001). Of the eligible patients with positive HCV Ab test results who could be linked to care, 45 (10.6%) were linked to care before HCV reflex implementation and 46 (14.2%) were linked to care with reflex testing (OR, 1.4; 95% CI: 0.9-2.2; P = 0.13). Conclusion: Implementing a reflex testing initiative into an HCV screening program in the ED can result in an increase of the percentage of patients who receive an HCV vRNA test after having had a positive HCV Ab. Hepatitis C virus vRNA reflex testing was not associated with a statistically significant increase in linkage-to-care rates for HCV Ab-positive patients; however, further studies are required.

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“…The first and main limitation of this study is the assumption for drop‐off rate for each scenario. Reports are scarce, therefore in the absence of Italian data we had to extrapolate from recent estimates reported in the literature 16,22,31 . Further in our analysis we considered 70% uptake for HCV screening as it was reported for other screening campaigns in Italy.…”

Section: Discussionmentioning

confidence: 99%

“…The strength of our study is that using a specifically designed Markov model of liver disease progression enables the evaluation of the relative costs of screening, treatment and overall disease costs, which change according to the proportion of undiagnosed patients assumed, based on data from real life studies 16 . Specifically, in a prospective study a substantial drop off rate of 45% occurred at the second visit for confirmatory serum/plasma testing, when the two steps diagnostic algorithm was applied 16 .…”

Section: Discussionmentioning

confidence: 99%

Optimizing diagnostic algorithms to advance Hepatitis C elimination in Italy: A cost effectiveness evaluation

Marcellusi

Mennini

Ruf

et al. 2021

Liver International

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Objectives Optimized diagnostic algorithms to detect active infections are crucial to achieving HCV elimination. We evaluated the cost effectiveness and sustainability of different algorithms for HCV active infection diagnosis, in a context of a high endemic country for HCV infection. Methods A Markov disease progression model, simulating six diagnostic algorithms in the birth cohort 1969‐1989 over a 10‐year horizon from a healthcare perspective was used. Conventionally diagnosis of active HCV infection is through detection of antibodies (HCV‐Ab) detection followed by HCV‐RNA or HCV core antigen (HCV‐Ag) confirmatory testing either on a second sample or by same sample reflex testing. The undiagnosed and unconfirmed rates were evaluated by assays false negative estimates and each algorithm patients’ drop‐off. Age, liver disease stages distribution, liver disease stage costs, treatment effectiveness and costs were used to evaluate the quality‐adjusted life‐years (QALYs) and the incremental cost‐effectiveness ratios (ICER). Results The reference option was Rapid HCV‐Ab followed by second sample HCV‐Ag testing which produced the lowest QALYs (866,835 QALYs). The highest gains in health (QALYs=974,458) was obtained by HCV‐RNA reflex testing which produced a high cost‐effective ICER (€891/QALY). Reflex testing (same sample‐single visit) vs two patients’ visits algorithms, yielded the highest QALYs and high cost‐effective ICERs (€566 and €635/QALY for HCV‐Ag and HCV‐RNA, respectively), confirmed in 99.9% of the 5,000 probabilistic simulations. Conclusions Our data confirm, by a cost effectiveness point of view, the EASL and WHO clinical practice guidelines recommending HCV reflex testing as most cost effective diagnostic option vs other diagnostic pathways.

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Towards the elimination of hepatitis C: implementation of reflex testing in Andalusia

Cited by 7 publications

References 23 publications

Elimination of Hepatitis C in Southern Italy: A Model of HCV Screening and Linkage to Care among Hospitalized Patients at Different Hospital Divisions

Elimination of Hepatitis C in Southern Italy: A Model of HCV Screening and Linkage to Care among Hospitalized Patients at Different Hospital Divisions

Hepatitis C Virus Reflex Testing Protocol in an Emergency Department

Optimizing diagnostic algorithms to advance Hepatitis C elimination in Italy: A cost effectiveness evaluation

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