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Clinical and Experimental Hepatology
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2/2020
vol. 6
 
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Original paper

Searching for the optimal population for hepatitis C virus screening in Poland

Anna Piekarska
1
,
Krzysztof Tomasiewicz
2
,
Waldemar Halota
3
,
Jerzy Jaroszewicz
4
,
Rafał Krygier
5
,
Piotr Małkowski
6
,
Małgorzata Pawłowska
3
,
Krzysztof Simon
7
,
Olga Tronina
8
,
Dorota Zarębska-Michaluk
9
,
Robert Flisiak
10

1.
Department of Infectious Diseases and Hepatology, Medical University of Łódz, Łódź, Poland
2.
Department of Infectious Diseases and Hepatology, Medical University of Lublin, Lublin, Poland
3.
Department of Infectious Diseases and Hepatology, Faculty of Medicine, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, Poland
4.
Department of Infectious Diseases, Medical University of Silesia, Katowice, Poland
5.
State University of Applied Sciences in Konin, Konin, Poland
6.
Department of Surgical and Transplantation Nursing and Extracorporeal Therapies, Medical University of Warsaw, Warsaw, Poland
7.
Department of Infectious Diseases and Hepatology, Wrocław Medical University, Wrocław, Poland
8.
Department of Transplantation Medicine, Nephrology, and Internal Diseases, Medical University of Warsaw, Warsaw, Poland
9.
Department of Infectious Diseases, Jan Kochanowski University, Kielce, Poland
10.
Department of Infectious Diseases and Hepatology, Medical University of Białystok, Białystok, Poland
Clin Exp HEPATOL 2020; 6, 2: 74–76
Online publish date: 2020/04/30
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Introduction

According to the most recent estimations, 71 million people are living with hepatitis C virus (HCV) infection worldwide [1]. The goal of the World Health Organization (WHO) strategy is elimination of viral hepatitis as a major public health threat. Since the global eradication of any infectious disease is possible only by a successful mass vaccination program, such a scenario is not attainable for HCV, because no vaccine against this virus is available. Introduction of highly effective and safe direct acting antivirals (DAA) has changed the landscape and perspectives of HCV treatment [2, 3]. Unfortunately, a large proportion of HCV-infected patients are still undiagnosed and at the risk of development of cirrhosis and/or hepatocellular carcinoma [4]. The major problem in European countries is lack of national screening programs, which is usually due to the lack of political will to spend additional money on searching for potential candidates for therapy. It is also related to difficulties in selection of so-called high risk groups among populations with relatively low HCV prevalence [5].

The purpose of the study was to analyze screening programs for anti-HCV carried out recently in Poland, to identify populations which demonstrate the highest antibody prevalence rate and therefore should be considered as an optimal target for a possible national screening program for HCV infection in Poland.

Material and methods

We collected data from a number of initiatives/actions of screening for anti-HCV antibodies, carried out in Poland in 2018 and 2019. The analysis included 723,654 participants from different populations and was performed by different organizations/institutions during different screening initiatives/actions. Data were collected by authors who were involved in particular activities as representatives of the Polish Expert Group for HCV. A description of each tested group is included in Table 1. Testing was performed in the whole blood using rapid anti-HCV kits, detecting antibodies generated against the proteins encoded by all HCV genotypes’ most conserved parts of Core, NS3, NS4, and NS5 regions in the HCV genome, which demonstrate sensitivity of 100% and specificity of 100% according to manufacturer (Türklab, Izmir, Turkey). During the initiative carried out by the diagnostic laboratories, presence of HCV RNA was additionally tested with the real-time polymerase chain reaction (RT PCR) method in 502 among 753 anti-HCV positive patients.

Table 1

Screening for anti-HCV initiatives/actions carried out in 2018 and 2019 in Poland (alphabetical order)

Initiative/actionDescription
Diagnostic laboratoryRapid testing in diagnostic laboratory network during HCV risk factors awareness campaign
Foundations, points of testingTesting during HCV awareness events organized by patient advocacy groups and foundations and testing at HIV consultation – diagnostic anonymous points where anonymously and without referral the patient can get HIV and HCV tests
General practitionersCooperation with family doctors’ offices, i.e. with GPs and nurses who performed testing of patients in area of their activity
HCV awareness weeksTesting during HCV awareness weeks in 10 biggest seaside healthy resorts
“Healthy Liver” programAnti-HCV testing was carried out in regional hepatologic clinical centers
HospitalsRapid HCV testing with education at admission to the large hospitals providing access to HCV therapeutic programs As a result identified patients received fast linkage to care
Local activities for seniorsUniversal, countrywide screening provided during events in nursing homes, diabetic clubs, senior clubs, registry office staff, social welfare homes, etc.
Music concertsThe biggest music festivals in Poland targeted for population including tattooed people and people who inject drugs
Private medical centersHCV testing in private medical center facilities (provided by entities other than government); selected age group 50+
SanatoriumsTesting was carried out in sanatoriums with predominant population of elderly
Summer outdoor eventsAddressed to participants of local events such as harvest festivals, sporting events (marathons, runs), other festivals
Production companiesTesting carried out in different production companies

Results

Altogether, 3,548 anti-HCV positive individuals were identified, so the prevalence rate in the whole studied population was 0.5%. The highest percentage (1.2%) was shown by diagnostic laboratories, which offered rapid testing to patients visiting their offices during the HCV awareness campaign. As demonstrated in Table 2 relatively high anti-HCV prevalence of 0.6-0.7% was noted in hospitals and in private medical centers, as well as during music concerts and in testing by foundations. Surprisingly, the lowest prevalence (0.2%) was observed in offices of general practitioners and in sanatoriums (Table 2). Among 753 anti-HCV positive individuals identified during the testing initiative in diagnostic laboratories, 502 were additionally tested for HCV RNA and 203 were viremic (40%).

Table 2

Prevalence of anti-HCV antibodies among those tested during different initiatives/actions carried out in 2018 and 2019 in Poland

InitiativeNumber
of people
tested
Number
of anti-HCV(+)
Preva-
lence
Diagnostic laboratory62,3057531.2%
Foundations, points of testing37,2202680.7%
Hospitals80,0825860.7%
Music concerts7,937460.6%
Private medical centers57,1633180.6%
“Healthy Liver” program8,876350.4%
HCV awareness weeks55,2091960.4%
Local activities for seniors43,0741420.3%
Summer outdoor events17,944460.3%
Production companies40,8251060.3%
Sanatoriums30,335590.2%
General practitioners91,7631390.2%
Other187,9275540.3%
All720,6603,2480.5%

Discussion

Hepatitis C virus surveillance in Poland has been measured with a number of epidemiologic studies carried out in the current century. Studies before 2010 were usually conducted in small, unrepresentative populations and demonstrated anti-HCV prevalence of 1-2%. Based on further studies we know that only 26-66% of individuals positive for anti-HCV are viremic, depending on the studied population [6]. In the current study we observed a 40% rate of viremic cases among anti-HCV positive individuals. However the first large epidemiologic study estimating the prevalence of HCV RNA positivity in Poland was conducted in the years 2009-2010 and included 26,057 individuals. This study demonstrated 0.6% incidence of viremic infections, which corresponded to 230 thousand Polish inhabitants, mostly unaware of the disease [6]. Another study, completed in 2016 within a Swiss Contribution program, confirmed 0.47% prevalence of HCV RNA among 21,875 individuals [7]. Despite HCV prevalence overestimation using anti-HCV testing compared to viremic testing, serial measurement of the anti-HCV positivity rate can be considered as a useful measure of changes in the HCV epidemiologic situation. The only such large study carried out in Poland was performed within 11 years in 61 805 persons and revealed a downward trend in anti-HCV antibody incidence from 3.2% in 2004 to 1.1% in 2014 [8]. However, the largest database of anti-HCV testing is presented in the current study, which included 720,660 people tested in 2018-2019. The average anti-HCV positivity rate of 0.5% confirms tendency demonstrated in the previously cited study. However, the most important message from our study is the indication where screening testing for HCV with rapid diagnostic kits should be carried out for better performance and further identification of candidates for highly effective treatment. It is clear from our study that testing for anti-HCV should be performed first of all in hospitals at the moment of patients’ admission, and in diagnostic laboratories, which can offer anti-HCV testing for patients referred due to any other laboratory analysis. Another good option seems to be anti-HCV testing in private medical centers. Based on the presented data we no longer recommend anti-HCV testing in the general practitioners’/family doctors’ offices, in sanatoriums or during local recreational events. On the other hand, there is a need to test populations which were not included in this study, such as drug users, inhabitants of small towns and villages with poor access to specialist health care, and finally prisoners.

In conclusion, anti-HCV testing in Poland should be carried out using rapid anti-HCV kits at the patients’ admission to the hospitals and should also be offered to patients during their visits for any purpose in diagnostic laboratories or private medical centers.

Disclosure

The authors report no conflict of interest.

References

1 

WHO. Global hepatitis report, 2017. Geneva, Switzerland: World Health Organization. http://apps.who.int/iris/bitstream/10665/255016/1/9789241565455-eng.pdf (access: 7.04.2019).

2 

Flisiak R, Zarębska-Michaluk D, Janczewska E, et al. Treatment of HCV infection in Poland at the beginning of the interferon-free era-the EpiTer-2 study. J Viral Hepat 2018; 25: 661-669.

3 

Flisiak R, Zarębska-Michaluk D, Jaroszewicz J, et al. Changes in patient profile, treatment effectiveness, and safety during 4 years of access to interferon-free therapy for hepatitis C virus infection. Pol Arch Intern Med 2020; 130: 163-172.

4 

Cook GS, Andrieux-Meyer I, Applegate TL, et al. Accelerating the elimination of viral hepatitis: a Lancet Gastroenterology & Hepatology Commission. Lancet Gastroenterol Hepatol 2019; 4: 135-184.

5 

Flisiak R, Frankova S, Grgurevic I, et al. How close are we to hepatitis C virus elimination in Central Europe? Clin Exp Hepatol 2020; 6: 1-8.

6 

Flisiak R, Halota W, Horban A, et al. Prevalence and risk factors of HCV infection in Poland. Eur J Gastroent Hepatol 2011; 23: 1213-1217.

7 

Rosińska M, Parda N, Kołakowska A, et al. Factors associated with hepatitis C prevalence differ by the stage of liver fibrosis: A cross-sectional study in the general population in Poland, 2012-2016. PLoS One 2017; 12: e0185055.

8 

Walewska-Zielecka B, Religioni U, Juszczyk G, et al. Anti-hepatitis C virus seroprevalence in the working age population in Poland, 2004 to 2014. Euro Surveill 2017; 22: pii: 30441.

Copyright: © 2020 Clinical and Experimental Hepatology. This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International (CC BY-NC-SA 4.0) License (http://creativecommons.org/licenses/by-nc-sa/4.0/), allowing third parties to copy and redistribute the material in any medium or format and to remix, transform, and build upon the material, provided the original work is properly cited and states its license.
 
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