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World Hepatitis Day 2021

What can COVID-19 teach us about eliminating viral epidemics as we mark World Hepatitis Day on July 28, 2021?
CATIE hepatitis

I don’t need to remind anyone about the immeasurable losses the COVID-19 pandemic has brought upon us.

There have been record levels of illness and death, not to mention the impact on our economies, social lives and mental well-being.  

We have seen some silver linings from our unprecedented response to COVID-19, such as the  implementation of mRNA vaccine technology. This would not have been possible without a significant investment of funds and human resources for research and development at a scale and intensity we have never seen before. And it is now likely that mRNA technology will be deployed against other illnesses.  

But there have been many other successes in the COVID-19 response — some more hidden than others — that we can also credit with slowing or reversing the course of the pandemic.

And we could leverage them to eliminate other viral epidemics in Canada.  

One of the most burdensome infectious diseases in Canada — to the health of individuals and to our health-care system — is hepatitis C.

Fortunately, there is a cure. Unfortunately, many people live with this infection for years before being diagnosed, with the virus wreaking havoc on the liver in the meantime, leading to liver cancer, cirrhosis and even death.

The only way to eliminate hepatitis C is to ensure everyone at risk has access to testing and curative treatments. But how would people know to get tested if hepatitis C often shows no signs or symptoms?

Offer testing more broadly

Historically, hepatitis C testing has been offered when a health-care provider believes a patient is currently at risk of infection. The problem with this approach is that health-care providers don’t always know their patients’ past or present risk factors.

The patients themselves may also have overlooked a potential exposure decades ago, such as sharing drug, tattoo or piercing equipment in their youth or receiving medical care in another country with less rigorous sterilization practices.  

We saw similar dynamics at play with the COVID-19 pandemic. Initial screening practices recommended testing only those who met very specific and obvious criteria, such as people with symptoms who had travelled to high-prevalence countries or regions. Part of this was due to rationing limited testing supplies and lab infrastructure, but this approach resulted in many cases going undiagnosed.

Now that we know more about the role of asymptomatic spread of COVID-19, a broader offer of testing has helped to stop some outbreaks in their tracks.  

Similarly, hepatologists and liver experts have been advocating for a broader approach to hepatitis C testing. Rather than limiting the offer of hepatitis C tests to people with symptoms or with current risk factors, Canadian liver specialists have advocated that everyone born between 1945 and 1975 also be offered a one-time hepatitis C test.

This approach, they argue, could put a dent into the large proportion of people living with chronic hepatitis C who don’t know they have it and could destigmatize the offer and the request of a hepatitis C test.

Focus on priority populations  

At the same time that COVID-19 testing criteria have been broadened, public health measures have become targeted.

The pandemic has exposed longstanding social, racial and class inequities that make some people more likely to have poor health and less likely to access health care. Some public health authorities recognized this, scaling up vaccine clinics and outreach in the neighbourhoods, workplaces and communities hardest hit by the pandemic. The strategy has paid off by focusing resources where they will have the most impact and breaking down barriers to healthcare services for Indigenous, black and other marginalized communities.  

Similarly, health advocates have been calling on governments to adopt a “priority population” approach to eliminate hepatitis C. This means acknowledging the communities most affected by hepatitis C — including older adults, Indigenous communities, immigrants from countries where hepatitis C is common and people who inject drugs — and prioritizing them for awareness-raising, testing initiatives and culturally relevant information in the languages they speak.

It can also take the form of a micro-elimination approach, such as dedicating the healthcare resources to completely eliminate hepatitis C from prisons, where hepatitis C is known to be easily transmitted.  

We have learned from COVID-19 that we can’t pretend all populations are at the same level of risk or receive the same level of healthcare access. We will only be effective if we adopt tailored strategies to address the unique factors that result in higher prevalence in certain communities.  

Tackle social risk factors  

Before the availability of safe and effective vaccines, most COVID-19 prevention measures were behavioural: avoiding close physical contact, wearing masks and washing hands. We also acknowledged the medical risk factors that could make a person more likely to become severely ill.  

But another welcome development in the COVID-19 pandemic was the decisive action taken by some governments to address the social determinants of health. Concerned that homeless people may be more vulnerable to COVID-19, some jurisdictions proactively offered temporary housing for people living in shelters, on streets and in parks.  

But the idea of offering housing as a public health measure is not new. Decades of research have shown that a lack of stable housing is associated with a greater risk of hepatitis C, among other health conditions. This pandemic has proven that we have the collective resources to house people when we want to prevent and eliminate a respiratory infection.

Why can’t we muster the resources to house people when we know it will also prevent and eliminate other infectious diseases?  

The social determinants of health extend beyond housing: income, access to education, food security, social inclusion and more. These are all effective public health measures that can’t be left out of our response to hepatitis C and other viral epidemics. 

Act now, save later  

The economic cost of COVID-19 is unparallelled. Jobs have been lost, trade has been hampered, entire industries have collapsed. The trickle-down effects on tax revenue and public spending are yet to be tabulated.

Hindsight is always 20/20, but you would be hard pressed to find an economist who would not see the value in governments having invested in stronger and more effective public health measures before the pandemic began.  

We can’t change the past, but we can learn from it. Looking forward, some have described hepatitis C as a ticking viral time bomb because the number of undiagnosed infections could lead to an unmanageable prevalence of liver disease and costs to the healthcare system in the future.

Hepatitis C in Canada currently costs us $160 million per year and this number is expected to increase to $260 million by 2032, when current cases develop complications.  

But if we changed our approaches now — broadening our testing strategies, focusing prevention efforts on priority populations, and ensuring everyone gets access to curative treatments — epidemiologists project that Canada could actually eliminate hepatitis C as a public health threat by 2030, saving millions of dollars in averted health-care costs.  

The COVID-19 pandemic has shown us what can go wrong when we don’t take action, and what we can achieve when we do. Whether decision-makers learn these lessons remains to be seen.  

Laurie Edmiston is executive director of CATIE, Canada’s source for HIV and hepatitis C information.