Will people with liver disease be prioritised for COVID-19 vaccination?

Image: Olena Yakobchuk/Shutterstock.com

People with decompensated cirrhosis should be prioritised for COVID-19 vaccination and immunosuppressive treatment after a liver transplant should not be a barrier to vaccination, an international panel of liver experts has concluded.

Their review of the available evidence is published in the journal The Lancet Gastroenterology and Hepatology.

They point out that the evidence on vaccine efficacy in people with chronic liver disease or post-transplant immunosuppression is very limited.

People with liver disease were included in the trials of the Pfizer and Moderna mRNA vaccines but excluded from the trials of the Oxford/AstraZeneca vaccine. People receiving immunosuppressive treatment after a liver transplant were excluded from trials of all three vaccines, as were people with autoimmune liver disease.

The review does not discuss the vaccine developed by the Chinese manufacturer Sinopharm, already in use in China, or the Russian Sputnik vaccine.

The experts warn that vaccine responses will need to be monitored in people with liver disease, as some liver conditions can weaken vaccine responses.  

People with cirrhosis are less likely to produce antibodies after hepatitis B vaccination and have less durable responses to flu vaccine. Similarly, people receiving immunosuppressive medication for liver transplantation have weaker antibody responses to flu and hepatitis B vaccinations.

People with decompensated cirrhosis must be a high priority group for vaccination, say the experts, due to their higher risk of death from COVID-19.

Although vaccinations are usually recommended prior to liver transplantation or after the transplant recipient has been stabilised on maintenance immunosuppressive treatment, the experts say that COVID-19 vaccination should not be delayed in liver transplant patients.

In the United Kingdom, the Joint Council on Vaccination and Immunisation has decided that people over 65 will be prioritised for vaccination, ahead of younger people with underlying health conditions including chronic liver disease.

Questions about COVID-19 vaccination for people with liver disease: guidance from patient associations and health bodies

Several patient groups and health bodies have published guidance and answers to frequently asked questions about COVID-19 vaccination. Some of this material is country-specific.

Public-sector hepatitis C treatment programmes expanding in lower- and middle-income countries

Public-sector hepatitis C treatment programmes have cured tens of thousands of people in lower- and lower-middle-income countries with the aid of low-cost direct-acting antivirals and diagnostics, a simplified approach to treatment and large-scale screening for hepatitis C, researchers report in BMJ Global Health.

The treatment programmes, established with the support of the Clinton Health Access Initiative between 2014 and 2017, had screened over 2.2 million people in seven countries by the end of 2019, of whom 120,522 people began direct-acting antiviral treatment after confirmation of chronic hepatitis C infection. Over 90% of those tested after completing treatment have been cured of hepatitis C.

In most cases, treatment was already being offered, often focused on people with HIV and hepatitis C co-infection. Since 2017, treatment has expanded in all countries. Examples include:

  • India: A demonstration programme in Punjab from 2016 provided a model for a national programme that aims to treat 300,000 people over three years.
  • Indonesia: Hepatitis C treatment programme expanded from seven to 15 provinces since 2017. A national hepatitis C elimination programme has been launched in prisons, to be expanded throughout the country.
  • Rwanda: High prevalence of hepatitis C (4%); Rwanda built on the success of its HIV treatment programme, beginning hepatitis C screening in people with HIV before expanding to national screening of 1.5 million by 2019 and a national commitment to eliminate hepatitis C by 2023.

Treatment access has been greatly aided by reductions in the costs of diagnostics and treatment. Rapid antibody test prices had fallen to around $1 per test by 2019 while viral load test prices have fallen from around $100 in 2014 to less than $15 a test. Generic versions of direct-acting antivirals cost $39 for a 12-week treatment course in India and $60 in Rwanda. The total commodity cost of curing hepatitis C in Rwanda is now less than $80 per person, compared to $923 in Vietnam and $781 in Indonesia.

What's needed to eliminate hepatitis C in people with HIV in Scotland?

Image: Street injecting site in Birmingham. Nigel Brunsdon/nigelbrunsdon.com

To eliminate hepatitis C in people with HIV in Scotland, healthcare providers will need to reach people not on HIV treatment and step up testing for hepatitis C in people who inject drugs, an analysis of Scottish surveillance data published in HIV Medicine shows.

Scotland has a high prevalence of hepatitis C among people with HIV, mainly due to sharing of injecting equipment. As in other European countries, people with HIV are an important group for focused efforts to eliminate hepatitis C – micro-elimination – because of the high rates of HIV diagnosis and engagement in care.

In 2018, the British HIV Association (BHIVA) set the target to cure hepatitis C in 80% of people with HIV by 2019 and all people with HIV by 2021.

People with HIV were identified through the national HIV surveillance database to the end of 2017 and matched with available hepatitis C testing data reported since 2000 in the four major health regions of Scotland.

The study found that 20% of people with HIV in Scotland had not been tested for hepatitis C between 2000 and 2017 and people who were not on HIV treatment were seven times more likely than those on treatment to be untested for hepatitis C.

Overall, the researchers estimate that 42% of those with hepatitis C in the study population had been cured by the end of 2017, far short of the BHIVA target of 80% cured by 2019.

The study authors emphasise the importance of following BHIVA guidance to test people with HIV at highest risk of hepatitis C exposure at least twice a year and to test everyone diagnosed with HIV for hepatitis C at least once.

Hepatitis C elimination in France feasible if new infections in gay and bisexual men decline

Hepatitis C is becoming more concentrated in gay and bisexual men with HIV in France as direct-acting antiviral treatment cures the infection in other people with HIV while hepatitis C transmission between gay and bisexual men increases, French epidemiologists report in the journal Clinical Infectious Diseases.

But Dr Laurent Cotte and colleagues involved in the Dat’AIDS cohort say that elimination of hepatitis C among people with HIV and hepatitis C co-infection is feasible if acute infections with hepatitis C can be prevented or detected and treated early.

The prevalence of hepatitis C is high among people with HIV in most European countries and elimination of hepatitis C in co-infected people will be essential to achieve global targets for hepatitis C elimination by 2030. France has declared that people with HIV and hepatitis C are a priority group for hepatitis C elimination.

Overall progress towards the World Health Organization’s hepatitis C elimination goals was good in all respects except reduction of new chronic infections. The target of diagnosing 90% of chronic infections was met by 2018 (95%), as was the target for treatment of 80% of chronic infections (88%) and a 65% reduction in deaths (no deaths due to hepatitis C in 2018, representing a 100% reduction). The target for reducing new chronic infections by 90% was not met; new infections in France fell by 35% between 2012 and 2018.

HIV doubles the risk of liver fibrosis by middle age, without viral hepatitis

Image: Shutterstock Studios

Having HIV almost doubles the risk of liver fibrosis, according to European research published in the online edition of the Journal of Infectious Diseases. Investigators in Denmark and the Netherlands compared rates of liver fibrosis between people living with HIV and people without HIV.

Launch of new international liver patients’ organisation: Liver Patients International

Liver Patients International (LPI), is an umbrella organisation which brings together expertise, experience and a passion to be the difference from a number of national patient organisations who already have a proven track record of leading change.

Founder members include the Hepatitis C Trust and PBC Foundation from the United Kingdom, the Dutch Liver Patients, Deutsche Leberhilfe from Germany and national patient organisations from Austria, Bulgaria, Greece, Italy, Romania and Switzerland.

“LPI was formulated by patient advocates with three common goals: to raise awareness, to share best practice, and to advocate for all of those affected by liver disease,” the group said in a press release. “We, as LPI, will continue striving for a better quality of life, better diagnostic and treatment facilities for people living with all kinds of liver diseases.”

Catch up on the World Hepatitis Alliance webinar on hepatitis B diagnostics

The World Hepatitis Alliance and the Foundation for Innovative New Diagnostics are running a series of webinars on diagnostics for viral hepatitis. You can catch up on the latest webinar on hepatitis B diagnostics here and download the slideset.

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