Slow progression of hepatitis C virus (HCV) infection can compromise liver function and lead to cirrhosis and hepatocellular carcinoma. The action of the virus is silent and can be maintained for years, but it is not inexorable: treatment with direct-acting antivirals (oral drugs and almost no side effects) cures the infection in practically all cases..

Spain is the country in the world that has treated the most patients with hepatitis C per million population: at least 165,000, say the Alliance for the Elimination of Viral Hepatitis in Spain (Aehve).. However, they also estimate that almost 30% of people with active infection are unaware of their situation. Most are between 40 and 69 years old..

Work is being done everywhere to detect these infected people as soon as possible and thus treat them, using different approaches. But the strategy that is being carried out in Galicia has some innovative ingredients that make it stand out from other formulas..

In addition, it invites us to think that the region will be the first in Europe to reach the goal of eliminating hepatitis C proposed by the World Health Organization (WHO).. An objective that pursues, among other indicators, to reduce, before 2030, new infections by 90% and deaths by more than 65% compared to 2015, when curative treatments appeared.

The Plan launched five months ago by the Galician Public Health Directorate contemplates opportunistic age screening, understood as the automatic offer of the hepatitis C test to any person of a certain age who for any reason goes to the health system and has to have a blood test.

The offer appears automatically, something possible thanks to the integration of the electronic medical record in the Galician community, and this avoids an unnecessary overload to the professional who cares for the patient, in addition to ensuring inclusion in the screening.

What does this screening or 'pooling' consist of?

In this first year it is offered to those between 50 and 59 years old; in the next two, people from 60 to 69 will be added first, and already in 2025, those from 40 to 49, until the target population group is completed. This screening is carried out in a pioneering way with a group of samples analyzed by PCR, a technique also known as pooling.

The pooling technique has already been used in the covid-19 pandemic, due to the shortage of reagents to perform RT-PCR tests. A study carried out by microbiologists Federico García (Granada University Hospital) and Antonio Aguilera (Santiago University Complex) and published in The Lancet Gastroenterology and Hepatology, endorsed its use in population screening for hepatitis C.

Juan Turnes, head of the Digestive System Service of the University Hospital Complex of Pontevedra (CHOP) and one of the specialists who has participated in the preparation of the Galician Plan, explains to this medium how the technique is applied.

“As far as we know, it is the only plan worldwide that is performing screening through pooling. We pool blood samples from 100 people to perform a single PCR, which costs around 30-40 euros. The estimated prevalence of the virus in people between the ages of 50 and 59 -those with the highest risk of hepatitis C in Spain- is 0.4-0.5%, that is, between four and five out of every 1,000 people.. With pools of 100 samples, it is very likely that many will be negative”.

With pooling, two things are sought, summarizes the specialist: on the one hand, to make quick and accurate diagnoses, something that the detection of antibodies does not offer, and that with RT-PCR is achieved in 24-48 hours.

Secondly, the grouping of samples “reduces costs in the Galician scenario of just over 50%”, a key element in the strategy to eliminate this viral hepatitis. “Although when talking about diseases, one usually thinks first of the cost of treatments, here the cost of detection and diagnosis has been given more weight. It must be taken into account that current drugs cure 100% of patients in practice: the few who do not respond to a first treatment do so to the rescue one”.

Carmen Durán Parrondo, general director of Public Health of the Galician Ministry of Health, points out that “in the first five months of development of the screening, 31,000 tests have been carried out and 38 cases of hepatitis C have been detected, that is, the monitoring of the program by professionals is high and its performance is consistent with the bibliography”.

And he adds that “from the General Directorate of Public Health we are convinced that this line of action together with the work with risk groups and primary prevention will contribute significantly to eliminating hepatitis C in Galicia, which is why progress is being made in other initiatives that can help speed up the phase-out process”.

Economic advantages of the technique

Juan Turnes is optimistic about the success of the strategy. “I am convinced that by 2024 we will have reached the WHO elimination criteria, although that does not mean that the plan will stop at that time, as there will still be people who are unaware that they have the infection”.

For the Aehve, the strategy of the Galician community marks “the path for all of Spain” and they ask the rest of the autonomies to follow their example by implementing opportunistic age screening through pooling.

“Doubts about opportunistic screening by age must be abandoned, since pooling samples means lower costs that make diagnostic efforts much more efficient and viable,” says the Aehve coordinator and head of the Hepatology Section of the University Hospital. La Paz, from Madrid, Javier García-Samaniego, who considers that the Galician experience provides sufficient evidence for a more ambitious review of the current diagnostic strategy of the Ministry of Health, currently limited to screening for risk factors.

For his part, Juan Turnes highlighted the support of the regional health authorities. He considers it “essential so that hepatologists can meet our objective of eliminating hepatitis C”, and stresses that the support comes from years ago, with different pilot projects that have served as proof of concept..

The specialist indicates that the plan in Galicia is completed with micro-elimination actions, aimed at small groups, such as people in prisons or among intravenous drug users.

And, within the macro-elimination strategy -aimed at large population groups- it also includes the search using artificial intelligence for people who at some point years ago were diagnosed with hepatitis C, but were never linked to treatment.

Artificial intelligence, a key resource

“We use artificial intelligence software from the Ministry of Health that was successful in a pilot test carried out in Pontevedra, during the pandemic. The tool was used to review thousands of histories in a semi-automatic way and thus we recovered (which implies the start of treatment) 60% of those people with the infection, a percentage higher than those reported in other countries of the European Union”.

One of the problems with screening is that not all people in whom the infection is detected are willing to start treatment.. If they are in the asymptomatic phase, they are fine; sometimes they belong to vulnerable groups that are not used to having contact with the health system.

However, explains Juan Turnes, “when the person has developed cirrhosis, it will not disappear. Although his vital prognosis will improve when treated, since the disease will not continue to progress, he will have a series of increased risks for life, for example, that of developing liver cancer.”.

There is still no data on what moment of the infection the 38 individuals in this plan were detected, but in the artificial intelligence search pilot test they found that of the 60% of people recovered, “one in four already had liver cirrhosis, and no symptoms”.

For this reason, Turnes considers it important to convey to the population that HCV infection has free treatment, lasting two to three months and is capable of curing practically one hundred percent of people with almost no side effects, to say none..

“Today a diagnosis of hepatitis C is not bad news, because detection, especially if it is early, will always be accompanied by a cure for the infection. In how many diseases can we say the same?”