Since 2019, around 1,000 immigrants from endemic countries have participated in a new model of diagnosis and management of viral hepatitis that has been designed by the Clinical Virology and New Diagnostic Approaches Research Group of the Germans Trias i Pujol Research Institute (IGTP), in the Microbiology Service of the Germans Trial Hospital (headed by Dr. Elisa Martró), along with the Public and Community Health Team (eSPiC) of Drassanes-Vall d'Hebron International Health Unit.

The HepClink project aimed to assess a new community intervention based on prevention, detection, and linkage for the management of subjects belonging to the Pakistani population in Catalonia who are infected with the Hepatitis C virus (HCV). This could be possible thanks to the joint efforts of the Centre for Epidemiological Studies of Sexually Transmitted Disease and AIDS in Catalonia (CEEISCAT), the eSPiC of Drassanes-Vall d'Hebron International Health Unit, and the Hepatology Service of Vall d'Hebron; as well as thanks to the support of the Public Health Agency of Catalonia (ASPCAT).

HepClink carried out a pilot Hepatitis C micro-elimination strategy in Pakistani population in Catalonia through the implementation of a community intervention. As Dr. Martró explained at the beginning of the project, "by reaching hidden populations in the community, we will generate strategic epidemiological information to quantify the problem and better understand the hepatitis epidemics in our setting. Therefore, the results we obtain will be useful for making evidence-based decisions and policies". Now, the results of the study, which have been recently published in Liver International, show that this intervention was accepted and effective for reaching a Pakistani immigrant population with scarce knowledge of the disease and who had mostly not been tested before. The prevalence observed and the lack of knowledge of their HCV infection status justify the targeted screening in this group, both on a community basis and on primary care.

"The keys to the success of HepClink are, on the one hand, the decentralized diagnosis offered in the HUGTIP and, on the other hand, the community-based strategy developed by the eSPiC. This team counts on a medical doctor and a nurse with great expertise in public health, as well as community health workers from Pakistan who have been trained to carry out specific community actions. These community actions include, at the same time, training through the HEPARJUEGO learning tool (which has been co-created with the community help), rapid diagnostic testing, and dried blood sampling by finger prick for detecting HCV RNA" explains Martró.

Towards the elimination of Hepatitis: the context of HepClink

Since 2015, Dr. Martró's group has been focusing on the simplification of the diagnosis of Hepatitis C, developing and validating an assay able to detect virus RNA using dried blood drops. This would improve the access to Hepatitis C diagnosis for vulnerable population (such as men who have sex with men, trans or male sex workers, people who inject drugs, and some immigrant groups).

As a result of the Plan for Prevention and Control of Hepatitis in Catalonia, as well as of the   Strategic plan for tackling hepatitis C in the Spanish National Health System (PEAHC), and in accordance with the WHO global health strategy -which establishes the objective of having eliminated this disease as public health problem by 2030-, the research group has been able to perform this pilot study thanks to the GILEAD grant received in 2019.

The assumption that gave rise to the project was that Pakistani immigrants could have a high HCV prevalence. Thus, the objective was to implement and evaluate the quality of a micro-elimination strategy based on a community intervention and to compare the data obtained with those from primary care.

¿How was the study carried out?

A total of 505 participants were recruited through the community intervention (64.6% men, median 37 years) versus those attending primary care (N = 25,455, 70.9% men, median 38 years).

Among the participants, 35.1% did not know about Hepatitis C and only 9.7% had been previously tested. The testing rate in the community intervention was 99.4% versus 50.7% in primary care.

The prevalence was 4.6% versus 7.1% (p = 0,008) for HCV antibodies, and 1.4% (3/6 new diagnoses) versus 2.4% (p = 0.183) for HCV-RNA. From the six viremic patients, three began treatment within the intervention and two through the usual circuit; with all of them completing the full course.

Project expansion: HepBClink

The HepClink project was expanded to HepBClink in 2020, extending the screening in order to test for both Hepatitis B and C, include more origin countries (immigrants from Senegal and Romania), and reach the Northern Metropolitan health area (incorporating the PROSICS Metro Norte and the Digestive Service of the Germans Trias Hospital as collaborators in the multidisciplinary working group that had already been created in the previous pilot study). Despite the COVID-19 pandemic, 492 patients have already been included in the study.

This project aims to achieve the micro-elimination of Hepatitis B and/or Hepatitis C in populations of immigrants from endemic countries and is based on the community intervention designed in the previous project (training, testing, and simplified access to treatment). The purpose of this study was to evaluate quality indexes and the efficiency of this intervention, for assessing its potential implementation.

*This study has been funded by Instituto de Salud Carlos III, grant PI19/0568 (co-funded by European Regional Development Fund "A way to make Europe")

*These two projects (HepClink and HepBClink), together with ASPCAT's MicatC project (a similar strategy in other geographical areas and migrants in other countries of origin) and ISGlobal's COMSAVA project (a community project to increase vaccination and link to the cure of hepatitis B in immigrants from West Africa in Catalonia) are part of a common strategy aligned with the Plan for the Prevention and Control of Hepatitis C in Catalonia.