Opportunistic screening by age and “pooling”

Gradual progression of hepatitis C virus (HCV) infection impairs liver function and leads to cirrhosis and hepatocellular carcinoma. The virus works silently and can persist for years, but it is not relentless: treatment with direct-acting antivirals (drugs taken orally with few side effects) cures the infection in almost all cases.

Spain has the highest number of treated hepatitis C patients per million population in the world: at least 165,000 people from Spanish Alliance for the Elimination of Viral Hepatitis (Aehve). However, they also estimated that nearly 30 percent of people with active infection were unaware of their condition.this Most are between 40 and 69 years old.

Efforts are being made everywhere to detect these infected people as quickly as possible so that they can be treated using different methods. But the strategy being implemented in Galicia has some innovative ingredients that make it stand out from other recipes.

Furthermore, it leads us to think that the region will be the first in Europe to achieve the hepatitis C elimination target set by the World Health Organization (WHO). Among other indicators, this goal pursues: Reduce new infections by 90% by 2030 Compared with 2015, when a curative treatment became available, the death toll was more than 65%.

The program was launched five months ago by the Galician Public Health Agency Consider opportunistic age screeningunderstood to automatically offer a hepatitis C test to anyone over a certain age who, for whatever reason, travels to the health system and must have a blood test.

This offer occurs automatically thanks to the integration of electronic medical records in the Galician community, which avoids unnecessary burdens on the professionals caring for the patients and ensures their inclusion in the screening.

What does this screening or “pooling” involve?

in this first year Provided to persons between the ages of 50 and 59; In the next two years, the 60-69-year-old group will be added first, and the 40-49-year-old group will start to be added in 2025 until the target population group is completed.The screening was conducted in a ground-breaking manner across a panel of samples Analysis by PCR, also known as collection.

of the technology collection It has been used in the covid-19 pandemic due to lack of reagents for RT-PCR testing.A study by microbiologists Federico García (University Hospital of Granada) and Antonio Aguilera (University Complex of Santiago) is published in The Lancet Gastroenterology and Hepatologyendorsing its use in population-based hepatitis C screening.

Juan Turnes, head of the Digestive Services at the University General Hospital of Pontevedra (CHOP) and one of the specialists involved in the development of the Galician plan, explained to this publication how the technology was applied.

“As far as we know, this is the only program in the world that screens using: collection.arriveWe group blood samples from 100 people and do a single PCR at a cost of about 30-40 Euros. Among the 50-59 year-old population at highest risk for hepatitis C in Spain, the prevalence of the virus is estimated to be 0.4-0.5%, or 4-5 per 1000 people. If the sample pool has 100 samples, it is likely that many samples will be negative. ”

along with collection Experts conclude that we are looking for two things: on the one hand, Make a fast and accurate diagnosisdoes not provide antibody detection, which can be achieved within 24-48 hours with RT-PCR.

Secondly, Sample grouping “reduces costs by more than 50% in Galician scenario”, a key element of this viral hepatitis strategy. “While the cost of treatment is usually the first thing that comes to mind when talking about disease, the cost of testing and diagnosis is more important here. It must be taken into account that current medicines cure 100% of patients in practice: the few that do. “Not responding to the first treatment, this was done as a rescue”.

Carmen Duran Palondo, Director General of Public Health at the Galician Ministry of Health, stated, “In the first five months of screen development, 31,000 tests were performed And 38 cases of hepatitis C were detected, that is, the follow-up rate of the program by professionals was high, and its performance was consistent with literature reports.”

He added, “The Directorate General of Public Health is convinced that this line of action, combined with work on high-risk populations and primary prevention, will make a significant contribution to the elimination of hepatitis C in Galicia, which is why other initiatives are progressing that will help to speed up the elimination process.

Economic advantages of the technology

Juan Ternes is optimistic about the success of the strategy. “I firmly believe that by 2024 we will have reached the WHO elimination criteria, but that doesn’t mean the program will stop at that point because there will still be people who don’t know they have the virus.”

For Aehve, the Galician community’s strategy marks “the path for the whole of Spain” and they ask other autonomous regions to follow their example by implementing opportunistic age screening collection.

“Skepticism about opportunistic screening by age must be abandoned, since pooling samples means lower costs and thus makes diagnosis more efficient and feasible,” said Aehve Coordinator and Head of the Department of Hepatology at the University Hospital La Paz from Madrid Javier García-Samaniego believes that Galicia’s experience provides enough evidence for a more ambitious review of the Ministry of Health’s diagnostic strategy, which is currently limited to screening for risk factors.

Juan Ternes emphasized the support of regional health authorities. He believes that “hepatologists must be able to achieve the goal of eliminating hepatitis C” and stresses that this support came many years ago and that different pilot projects have served as proofs of concept.

Experts say the Galician program is done through micro-elimination operations targeting small groups, such as those in prisons or intravenous drug users.

And, in a broader elimination strategy for large populations, it also includes using artificial intelligence to search for people who were diagnosed with hepatitis C sometime years ago but were never linked to treatment.

AI, key resource

“We use a software A pilot test of the Ministry of Health’s AI in Pontevedra during the pandemic has been successful. The tool was used to review thousands of histories in a semi-automated manner, so we recovered (meaning started treatment) 60% of those infected, a higher rate than reported by other countries in the EU. “.

One of the problems with screening is that not everyone whose infection is detected wants to start treatment. If they’re in the asymptomatic phase, that’s fine; sometimes they’re vulnerable groups who aren’t used to interacting with the health system.

However, Juan Turnes explained, “When a person develops cirrhosis, it doesn’t go away. Although the prognosis for their life improves after treatment, they face a series of increased risks to their life because the disease will not continue to progress. , for example, to develop liver cancer”.

There is no data yet on when the 38 people in the program were detected, but in a pilot test of the AI ​​search they found that of the 60% who recovered, “a quarter already had liver disease.” sclerosis, and no symptoms.

For this reason, Turns believes it is important to convey to people that HCV infection is free to treat, lasts two to three months, and can cure almost 100 percent of people with few or no side effects.

“Today, a diagnosis of hepatitis C is not bad news because detection, especially early detection, is invariably accompanied by cure of the infection. How many diseases can we say the same?”