Covid-19 and adults living with hepatitis C, or the complications of previous hepatitis C virus (hcv) infection
ASHM COVID-19, BBV AND SH REGIONAL ADVISORY GROUP INTERIM RECOMMENDATIONS
Prepared by Dr. Robert Batey, and members of the Taskforce and Regional Advisory Group viral hepatitis sub-groups
UPDATED ON: 17 June 2020
The guidance is adapted from the ASHM COVID-19 Taskforce interim recommendations regarding COVID-19 and adults living with chronic hepatitis B.
Disclaimer: The recommendations provided are the opinions of the authors and are not intended to provide a standard of care, or practice. This document does not reflect a systematic review of the evidence but will be revised to include relevant future systematic review findings. The recommendations are not intended to replace national guidance.
In the general community, people over 60 years of age and people with co-morbidities including hypertension, cardiovascular disease, lung disease, cancer, diabetes and chronic liver disease are at greater risk of poorer outcomes with COVID-19 illness(1-4). Indigenous peoples, particularly those with one or more chronic medical conditions, may be at greater risk of serious COVID-19 illness. Hence people with chronic hepatitis C who are older and/or have co-morbidities are also likely to be at greater risk of having poorer outcomes with the COVID-19 illness. People living with hepatitis C who have cirrhosis are likely to have an increased risk of severe illness due to COVID-19; particular attention must be given to optimising their health and reducing their risk of infection with SARS-CoV-2.
Measures to optimise these patients’ health should include supporting smoking cessation, optimising diabetic and blood pressure control. We do not recommend ceasing or switching away from ACE inhibitors or angiotensin receptor blocker medications: there is no evidence that these agents increase the risk of worse outcomes of COVID-19 illness (5) and ceasing or switching these agents may cause harm to otherwise stable patients.
Optimising the treatment and management of people with hepatitis C, particularly those with cirrhosis +/- HCC, including the initiation of antiviral treatment is important during the COVID-19 pandemic. In general, patients with hepatitis C should be commenced on direct-acting antiviral (DAA) therapy, if it is available and accessible through free government programs in accordance to respective countries’ national guidelines.
DAA initiation could be deferred in patients with pre-cirrhosis stages of liver disease, if clinical services are constrained. In patients commenced on DAA therapy, strategies to limit direct healthcare service engagement can be considered. Many patients will not require clinical follow-up during the 12 weeks of DAA therapy. However, follow-up using Telehealth, including telephone calls may be necessary during this period for some patients where there are concerns about poorer adherence to DAA therapy, or risk of hepatitis C reinfection. After DAA therapy is completed, the routine follow-up blood test to confirm sustained virological response can be deferred for 3-6 months.
For patients with cirrhosis, surveillance ultrasounds for HCC should not be deferred, but consideration should be given to ordering these through available and affordable private radiology practices if they are usually performed in public hospitals. These patients should be considered for treatment with direct acting antiviral agents (DAA’s) if they have no evidence of HCC subject to affordable DAA is available through government program and private health settings. Patients with decompensated cirrhosis should be referred to specialist units for management within the appropriate national healthcare system and in accordance with national guidelines.
There is no current evidence that being infected with hepatitis C is associated with a relative increase in the risk of acquiring SARS-CoV-2 infection, or a relative increase in the risk of worse outcomes with COVID-19 illness.
Some people with hepatitis C may be at higher risk of SARS-CoV-2 infection and severe COVID-19 illness. Some people with hepatitis C may have a greater level of immunosuppression than others and may be more vulnerable to infection with SARS-CoV-2 and more severe COVID-19 illness. We currently suggest that the following patient groups with hepatitis C may be more vulnerable to poorer outcomes with COVID-19 illness because of immunosuppression
People with hepatitis C or cirrhosis +/- HCC should receive the same supportive treatment for COVID-19 illness as people without hepatitis C or cirrhosis +/- HCC, noting that some people with hepatitis C or cirrhosis +/- HCC will be immunosuppressed, have cirrhosis, be older and/or have co-morbidities. It has been hypothesised that non-steroidal medications (NSAIDS) may exacerbate COVID-19 illness, (10) although there is limited evidence to support this. Until more data are available, clinicians might consider using paracetamol for management of symptoms of COVID-19 illness, in preference to use of ibuprofen and other NSAIDS. Specialist medical and pharmaceutical advice should be sought for patients with hepatitis C or cirrhosis +/- HCC who are hospitalised with COVID-19 illness. Patients with hepatitis C or cirrhosis +/- HCC should be included in all appropriate COVID-19 clinical treatment trials.