- Canada signed on to international goals to eliminate hepatitis C as a public health issue by 2030
- With current testing and treatment rates, Manitoba, Ontario and Quebec will not meet this goal
- Missing these goals will cost Canada more than $120 million in healthcare spending
Hepatitis C virus (HCV) can infect the liver and cause chronic infection within this vital organ. Over time, the liver becomes inflamed because of this viral infection. Chronic HCV infection (and associated inflammation) gradually causes healthy liver tissue to be replaced with scar tissue. At first, chronic HCV infection is usually symptom free and may go unrecognized by people for many years. However, as the functioning of the liver gradually degrades, persistent fatigue sets in and complications can occur, including serious abdominal infections, internal bleeding, fluid buildup and difficulty with memory and thinking clearly. As scar tissue accumulates, the risk for liver cancer and death is heightened.
HCV can be detected with a simple blood test. Medicine (in the form of pills) is available that is highly effective at curing people. Treatment is generally safe and can be taken once daily. A course of treatment lasts between eight and 12 consecutive weeks and cures more than 95% of people.
Goals to elimination
The World Health Organization (WHO) has set goals that cities, regions and countries can strive to reach in order to help reduce HCV as a public health issue. These goals include offering screening for HCV and treatment for when this infection is found so people can be cured. In particular, the WHO targets include an 80% reduction in new chronic infections and a 65% reduction in deaths compared to levels in 2015. As efforts to increase screening and treatment are intensified, WHO predicts that it will be possible to eradicate HCV as a public health issue. WHO has set goals and targets so that HCV can be eliminated by 2030.
In Canada
The Canadian Network on Hepatitis C (CanHepC) has released a blueprint to help guide efforts to eliminate HCV as a public health issue. The blueprint emphasizes engagement with priority populations affected by HCV.
Off track
The COVID-19 pandemic has had an enormous impact on societies, economies and health systems. For instance, early in the pandemic, hospitals, clinics and ministries of health all shifted from their regular work to prioritizing care for people with COVID-19. Research from the early period of the pandemic found that the annual rate of HCV treatment fell compared to several years before the pandemic occurred. Due to this decline, Canada fell behind WHO elimination goals for HCV. If Canada does not take steps to regain lost momentum in rates of HCV treatment, reaching the goal of eliminating HCV by 2030 will become difficult.
Canadian research
A team of researchers in several Canadian provinces engaged in a complex study that incorporated a range of information, including rates of HCV testing and diagnoses, annual treatment and other HCV-related health issues. The researchers also incorporated economic data about the impact of HCV.
The team found that if diminished rates of HCV treatment continue, the provinces of Manitoba, Ontario and Quebec would not achieve WHO elimination goals by 2030. Furthermore, by missing the elimination targets, these provinces would have to spend more than CAN $122 million on medical costs arising from chronic HCV and its complications.
Canada needs to invigorate the struggle against HCV so that it can realize the promise of better health that comes with curing an infection and save money in the long term.
Study details
Researchers developed a computer model that took into account huge amounts of health and economic-related information on the HCV epidemic in Canada.
Results
If current rates of annual HCV testing and treatment continue, the following seven Canadian provinces would reach WHO HCV elimination goals by 2030:
- Alberta
- British Columbia
- New Brunswick
- Newfoundland and Labrador
- Nova Scotia
- Prince Edward Island
- Saskatchewan
The model predicted that if annual rates of HCV testing and treatment fell by 10%, the following five provinces would still meet WHO’s 2030 elimination goals:
- New Brunswick
- Newfoundland and Labrador
- Nova Scotia
- Prince Edward Island
- Saskatchewan
However, it would take until the year 2040 for provinces such as Alberta and British Columbia to eliminate HCV. What’s more, three other provinces—Manitoba, Ontario and Quebec—would not be able to eliminate HCV until 2050.
If there was a 20% decline in the annual rate of HCV diagnosis and treatment, only the following four provinces would be able to eliminate HCV as a public health threat by 2030:
- Newfoundland and Labrador
- Nova Scotia
- Prince Edward Island
- Saskatchewan
In this case, it would take until 2050 for New Brunswick to eliminate HCV, and the remaining five provinces would not eliminate HCV by 2050.
The researchers also made the computer model look at positive trends—a 10% annual increase in HCV diagnoses and treatment. In such a scenario, the model predicted that the following provinces would achieve WHO HCV elimination goals by 2030:
- Alberta
- British Columbia
- New Brunswick
- Newfoundland and Labrador
- Nova Scotia
- Ontario
- Prince Edward Island
- Saskatchewan
The model also predicted that under that scenario Manitoba and Quebec would reach HCV elimination goals by 2031.
The researchers were able to estimate specific numbers of people that would need to be cured each year to enable HCV elimination by 2030 in three provinces:
- Manitoba – 540 people cured annually
- Ontario – 7,700 people cured annually
- Quebec – 2,800 people cured annually
Rates of testing
A key component essential to reaching the 2030 HCV elimination goal is offering testing to uncover HCV infection. The researchers stated: “…maintaining a constant annual diagnosis level would likely require an increasing number of annual HCV antibody screens: as the undiagnosed HCV-infected population shrinks, the number needed to screen and identify any additional HCV-infected case rises.”
Saving money
According to the researchers, eliminating HCV by 2030 would save some provinces substantial sums of money that otherwise would have been spent on treating complications arising from chronic HCV infection:
- Manitoba – $10.6 million
- Ontario – $114.5 million
- Saskatchewan – $31.2 million
Efforts need to be refined to help reach more people
Some of the researchers' projections about what needs to be done to eliminate HCV may be optimistic. They note that before the onset of the COVID-19 pandemic, between the years 2018 and 2019, several provinces experienced a reduction in rates of annual treatment as follows:
- British Columbia – a 25% decline
- Alberta – a 12% decline
- Ontario – a 17% decline
- Quebec – a 22% decline
Although data are incomplete, a partial analysis of data from 2018 to 2019 suggests that reductions in rates of annual HCV treatment also occurred in Manitoba (-19%) and Saskatchewan (-26%).
The researchers are not certain why rates of HCV treatment were in decline prior to the onset of the COVID-19 pandemic, but they advanced the following points:
- Traditional models of treatment may have “increasing difficulty reaching populations living with HCV.”
- Previous modes of HCV care delivery that were developed for the implementation of interferon-based therapy or that dealt mainly with baby boomers “may be less effective when reaching individuals from priority populations […] who contend with oppression, sometimes from multiple intersecting sources.”
Priority populations
The researchers stated that in Canada HCV disproportionally affects priority populations. They encouraged health systems to focus on priority populations to achieve the 2030 WHO elimination goals. The researchers made specific recommendations about priority populations, including the following:
Immigrants and newcomers
“Making voluntary HCV screening and linkage to care available to newcomers upon arrival to Canada would help identify these cases early.”
People who inject/use drugs
“Scaling up evidence-based harm-reduction services such as needle and syringe programs, opioid substitution therapy, and supervised consumption services would help reduce the rising HCV incidence rates.” The researchers also noted that “voluntary HCV testing in harm-reduction settings for infection and reinfection would help identify new cases.”
Indigenous peoples
“HCV care models that are culturally sensitive and stigma free have been proposed to alleviate the HCV disease burden among this priority population, but very limited efforts have been made to truly engage with and support Indigenous leaders, healthcare providers, and individuals with lived/living experience to develop and implement culturally safe and responsive, effective HCV care models. The huge burden of HCV in Indigenous communities across the country relates directly to the legacy and harms of colonialism and resulting intergenerational trauma. Meaningful reconciliation entails addressing HCV while working towards structural changes that further enhance equity.”
Baby boomers
The researchers stated that people born between 1945 and 1975 have the highest rate of HCV in Canada (compared to people born in other periods). “To detect HCV among this subpopulation, countries such as the United States have recommended birth-cohort-based, in addition to risk-factor-based, screening. Data have shown that a similar strategy would be cost effective in Canada; however, to date, only British Columbia has adopted birth-cohort-HCV screening. With the rising HCV incidence among younger individuals related to the opioid epidemic, consideration of other approaches to population-level screening, such as one-time screening of all adults, should be evaluated.”
People with experience in the prison system
According to the researchers, people who are or have been incarcerated have a higher risk for HCV infection than the average person in Canada who has no experience in the prison system. Offering routine opt-out HCV testing and linking people who test positive to care has been “effectively implemented in federal prisons, but to date, provincial prisons/jails have been slow to adopt screening, treatment or harm-reduction services. Models used for COVID-19 screening could be effectively adapted to HCV. Addressing HCV in the prison setting has a positive spill-over effect to community HCV transmission and should be prioritized.”
Gay, bisexual and other men who have sex with men
“An increasing trend of HCV cases has been reported among gay, bisexual, and other men who have sex with men, a subpopulation that also intersects with other priority populations. Integrating opt-out HCV testing services and options for linkage-to-care and treatment into other sexual health services, such as pre-exposure HIV prophylaxis, may be an efficient way to identify HCV infection among this population.”
Helping people excluded from mainstream healthcare
The researchers stated: “Some of the priority populations, such as people with experience in the prison system and gay, bisexual and other men who have sex with men, contribute to a smaller portion of the national HCV prevalence; however, they are often excluded from mainstream healthcare and face higher levels of stigma. Hence, any HCV elimination effort should include a specific focus on these groups and all priority populations, given that they experience a disproportionate burden of HCV or have challenges accessing HCV care and services. Inclusion of all priority populations in provincial HCV strategies would help place focus on these subpopulations. However, of the 10 provinces studied, only two (Alberta and Prince Edward Island) even have a strategy document in place to address HCV elimination.”
Meeting the challenge
The researchers stated that “returning [HCV] treatment capacity to pre-pandemic levels will be a significant challenge, as it will require training of new personnel, since many community-based clinics were closed for months and team members may have moved to other work. On the HCV diagnosis front, both weekly HCV testing and first-time HCV-positive diagnosis rates from British Columbia saw an initial decline followed by a recovery to pre-pandemic levels, while data from Ontario showed declines with each COVID-19 wave followed by recovery but never to pre-pandemic testing rates. Ideally, public health testing capacity that was greatly expanded for COVID-19 could be used to enhance HCV testing across the country. Since the future trajectory of diagnosis and treatment levels is unknown, our analysis considered both pre- and post-pandemic status quos to account for this uncertainty.”
The researchers also stated that “the consequences of the COVID-19 pandemic reach beyond the variables accounted for by our modelling study. The trend of delivering healthcare virtually via telemedicine, as emphasized during the pandemic, can simplify HCV care but we need to continue to advocate for those individuals for whom digital health care is inaccessible.”
For the future
The COVID-19 pandemic has affected access to services for the prevention, care and treatment of many conditions, including hepatitis C. The study by Canadian researchers underscores the urgency for invigorating the struggle against HCV. By providing recommendations, the researchers have helped pave the way for provinces to move forward so that they can reach the WHO targets by 2030.
—Sean R. Hosein
Resources
Hepatitis C testing and diagnosis – CATIE
Blueprint to inform Hepatitis C elimination efforts in Canada – Canadian Network on Hepatitis C
Hepatitis C – World Health Organization
REFERENCES:
- Feld JJ, Klein MB, Rahal Y, et al. Timing of elimination of hepatitis C virus in Canada’s provinces. Canadian Liver Journal. November 2022;5(4):493-506.
- Pedrana A, Munari S, Stoové M, et al. The phases of hepatitis C elimination: achieving WHO elimination targets. Lancet Gastroenterology and Hepatology. 2021 Jan;6(1):6-8.
- Maringe C, Spicer J, Morris M, et al. The impact of the COVID-19 pandemic on cancer deaths due to delays in diagnosis in England, UK: a national, population-based, modelling study. Lancet Oncology. 2020 Aug;21(8):1023-1034.
- Anonymous. Too long to wait: the impact of COVID-19 on elective surgery. Lancet Rheumatology. 2021 Feb;3(2):e83.