COVID-19 and adults living with hepatitis C, or the complications of previous hepatitis C infection
ASHM COVID-19 Taskforce interim recommendations
UPDATED ON: 16 April 2020.
Disclaimer: This ASHM document is designed to provide available, relevant information to clinicians and other healthcare providers to optimise the health and wellbeing of people living with hepatitis C or cirrhosis +/- HCC during the COVID-19 pandemic. 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 of the National COVID-19 Clinical Evidence Taskforce(1) and other relevant information.
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(2-6). The Australian Government Department of Health has advised that Aboriginal and Torres Strait Islander people 50 years and older, with one or more chronic medical conditions, may be at greater risk of serious COVID-19 illness. Hence older people living with hepatitis C infection, or with cirrhosis +/- HCC and co-morbidities will also be at greater risk of COVID-19 illnes.
Measures to optimise these patients’ health should include supporting smoking cessation, optimising diabetic and blood pressure control. We currently recommend not ceasing or switching away from ACE inhibitors or angiotensin receptor blocker medications: there is not enough evidence that these agents increase the risk of worse outcomes of COVID-19 illness(7) and ceasing or switching these agents may cause harm to otherwise stable patients. Other key measures include encouraging appropriate exercise, maintaining regular appointments via Telehealth which includes telephone consultations, or face-to- face if required, streamlining dispensing of scripts and blood slips, supplying supporting documents for financial assistance and actively referring and encouraging patients to attend Telehealth appointments with medical and allied health specialists. Clinicians should encourage patients to consider Advance Care Planning, as discussed in a recent paper on the clinical presentation and management of COVID-19(8)
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(9) according to the recommendations of the Gastroenterological Society of Australia (GESA)(10). 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. Individuals should be reminded that general practitioners and nurse practitioners can prescribe hepatitis C treatment, and may have more capacity than hospital services to provide hepatitis C care at this stage. Many patients will not require clinical follow-up during the 12 weeks of DAA therapy(10). 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 re-infection(10). 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 community radiology practices if they are usually performed in public hospitals. When gastroscopies for surveillance, or banding of oesophageal varices are indicated, these should not be routinely deferred. However access to these services is becoming increasingly limited because of the high risk of SARS-CoV-2 transmission and discussion with a gastroenterologist/hepatologist is recommended on a case-by-case basis. We recommend referring to the GESA COVID-19 consensus statements for regular updates on changes in procedural practices relevant to people with hepatitis C(11).
• People with hepatitis C, or cirrhosis +/- HCC may be currently using injectable drugs and require ongoing access to sterile injecting equipment
• Opioid substitution therapy (OST) should be offered where appropriate to people with hepatitis C, or cirrhosis +/- HCC. Clinicians should liaise with pharmacies to ensure appropriate take-away doses of OST are made available for their patients
• All people with hepatitis C, or cirrhosis +/- HCC should be offered the influenza vaccine
• People living with cirrhosis are at increased risk of invasive pneumococcal disease and of severe outcomes of influenza infection. Appropriate vaccination can help prevent infections and keep people living with liver disease healthy, and also avert the need for medical care or hospitalisation at a time when the health system may be seriously challenged by COVID-19.
• People with chronic liver disease are recommended to receive 3 doses of 23-valent pneumococcal polysaccharide vaccine – one at diagnosis, a 2nd dose at least 5 years later, and a 3rd dose at least 5 years after the 2nd dose or at age 50 years for Aboriginal or Torres Strait Islander people, or 65 years for non-Indigenous people, whichever is later.
• People with chronic liver disease are also recommended to receive annual influenza vaccine. Further information is available in the Australian Immunisation Handbook - https://immunisationhandbook.health.gov.au/
• All people with hepatitis C, or cirrhosis +/- HCC, including young and well patients should be supported to cease smoking, exercise appropriately, optimise their sleep and adhere to the current National Health and Medical Research Council draft recommendations on alcohol intake(12). Note that for patients living with cirrhosis, no level of alcohol intake is considered safe and they should be supported to cease consuming alcohol.
• Mental health issues may become more common, or more severe during the COVID-19 pandemic
• Financial insecurity may impede people meeting their hepatitis C healthcare needs and may lead to housing insecurity
• Domestic violence rates have escalated globally since COVID-19 emerged
• People with substance use disorders might place themselves at greater risk of acquiring COVID-19 to obtain non-prescription drugs because social distancing is harder to maintain
• There may be changes in supply of heroin and other drugs during the COVID-19 pandemic which may lead to opioid withdrawal, greater demand for access to OST and untoward side-effects of alternative drugs
Clinicians are encouraged to use regular appointments to routinely evaluate these issues in all people with hepatitis C, or cirrhosis +/- HCC and refer to drug and alcohol services, specialists, community nurses, social workers, peer support, community organisations and other appropriate services, as needed. Clinicians should encourage patients to seek help between appointments if these issues arise.
• There are reports that people who inject drugs and who are trying to adhere to social isolation laws are concerned about overdosing alone. Therefore it is essential that people who inject drugs during the COVID-19 pandemic are provided with Naloxone for overdose reversal. In addition clinicians should their patients to connect with friends via telephone/Facetime when they are injecting to minimise the risk of fatal overdose and use Supervised Injecting Facilities in Melbourne and Sydney.
• Some culturally and linguistically diverse populations (CALD) report concerns regarding the term ‘social distancing’ and prefer the term ‘physical distancing’
• CALD populations report concerns about being hospitalised with COVID-19 and having reduced opportunities to use appropriate medical translation services. Clinicians should undertake to optimise appropriate translation services at all opportunities
• Achieving social distancing and self-quarantine may be impossible in overcrowded houses, prisons, detention centres and in homeless settings. Clinicians should advocate for their patients with hepatitis C, or cirrhosis +/- HCC who are experiencing these conditions to receive urgent support to optimise their protection against SARS-CoV-2 infection
• People with hepatitis C, or cirrhosis +/- HCC who are prevented from returning to their home countries may be concerned about being able to afford their antiviral treatment in Australia. Clinicians should contact hepatitis peak organisations (see https://www.hepatitisaustralia.com/members-and-supporters) and speciality pharmacists to canvass any currents arrangements and plans to support these patients
• Medicare ineligible people who remain in Australia and who require medical care including hospitalisation as a result of SARS-CoV-2 infection are concerned about incurring high medical costs in some jurisdictions
There are no data currently available that demonstrate that hepatitis C antiviral medications can prevent infection with SARS-CoV-2.
It is currently unknown whether being infected with hepatitis C is itself 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 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
• Those with cirrhosis
• Those who have had a liver transplant and therein must take life-long immunosuppressive therapy
• Those with hepatocellular carcinoma
Early reports on pregnant women with COVID-19 illnesses reveal no maternal deaths, and report that the clinical features and outcomes of COVID-19 illness are not different from non-pregnant women with COVID-19 illness(13-15). Existing evidence suggests people aged under 50 years and females are less likely to have severe outcomes from COVID-19 infection, but more data are awaited to inform the specific situation of pregnant women There has been one report of mother-to-child transmission of the SARS-CoV-2 virus and the neonate developed pneumonia, but recovered fully(14). There are no current data on outcomes of pregnant women with hepatitis C, or cirrhosis +/- HCC who develop COVID-19 illness and their newborns. Clinicians are advised to seek specialist advice to optimise health outcomes for women with hepatitis C, or cirrhosis +/- HCC who are seeking to become pregnant, or who are currently pregnant during the COVID-19 pandemic.
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, (16) 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.
Note that recommended measures to protect against SARS-CoV-2 infection may vary between jurisdictions, but in all jurisdictions the following measures are critical:
• Social/physical distancing
• Regular hand washing
• Refraining from touching the face
• Cough etiquette
• Social quarantine following contact with person with proven or suspected COVID-19 illness
1. National COVID-19 Clinical Evidence Taskforce https://covid19evidence.net.au/.
2. Wang, D., B. Hu, C. Hu, F. Zhu, X. Liu, J. Zhang, B. Wang, H. Xiang, Z. Cheng, Y. Xiong, Y. Zhao, Y. Li, X. Wang, and Z. Peng. 2020. Clinical Characteristics of 138 Hospitalized Patients With 2019 Novel Coronavirus-Infected Pneumonia in Wuhan, China. JAMA.
3. Wu, Z., and J. M. McGoogan. 2020. Characteristics of and Important Lessons From the Coronavirus Disease 2019 (COVID-19) Outbreak in China: Summary of a Report of 72314 Cases From the Chinese Center for Disease Control and Prevention. JAMA.
4. Zhou, F., T. Yu, R. Du, G. Fan, Y. Liu, Z. Liu, J. Xiang, Y. Wang, B. Song, X. Gu, L. Guan, Y. Wei, H. Li, X. Wu, J. Xu, S. Tu, Y. Zhang, H. Chen, and B. Cao. 2020. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet 395: 1054-1062.
5. Severe Outcomes Among Patients with Coronavirus Disease 2019 (COVID-19) United States, February 12–March 16, 2020. MMWR Morb Mortal Wkly Rep. .
6. Porcheddu, R., C. Serra, D. Kelvin, N. Kelvin, and S. Rubino. 2020. Similarity in Case Fatality Rates (CFR) of COVID-19/SARS-COV-2 in Italy and China. J Infect Dev Ctries 14: 125-128.
7. Vaduganathan, M., O. Vardeny, T. Michel, J. J. V. McMurray, M. A. Pfeffer, and S. D. Solomon. 2020. Renin-Angiotensin-Aldosterone System Inhibitors in Patients with Covid-19. N Engl J Med.
8. Thevarajan, I., K. L. Buising, and B. Cowie. 2020. Clinical presentation and management of COVID-19 https://www.mja.com.au/journal/2020/clinical-presentation-and-management-covid-19.
9. PBS General Statement for Drugs for the Treatment of Hepatitis C http://www.pbs.gov.au/healthpro/explanatory-notes/general-statement-pdf/general-statement-hepatitis-c.pdf.
10. Hepatitis C Virus Infection Consensus Statement Working Group. Australian recommendations for the management of hepatitis C virus infection: a consensus statement (September 2018). Melbourne: Gastroenterological Society of Australia, 2018. https://www.google.com/search?q=Australian+recommendations+for+the+management+of+hepatitis+C+virus+infection%3A+a+consensus+statement+(September+2018)&oq=Australian+recommendations+for+the+management+of+hepatitis+C+virus+infection%3A+a+consensus+statement+(September+2018)&aqs=chrome..69i57.567j0j1&sourceid=chrome&ie=UTF-8.
11. Gastroenterology Society of Australia https://www.gesa.org.au/news/.
12. Australian guidelines to reduce health risks from drinking alcohol https://www.nhmrc.gov.au/health-advice/alcohol.
13. Schwartz, D. A. 2020. An Analysis of 38 Pregnant Women with COVID-19, Their Newborn Infants, and Maternal-Fetal Transmission of SARS-CoV-2: Maternal Coronavirus Infections and Pregnancy Outcomes. Arch Pathol Lab Med.
14. Yu, N., W. Li, Q. Kang, Z. Xiong, S. Wang, X. Lin, Y. Liu, J. Xiao, H. Liu, D. Deng, S. Chen, W. Zeng, L. Feng, and J. Wu. 2020. Clinical features and obstetric and neonatal outcomes of pregnant patients with COVID-19 in Wuhan, China: a retrospective, single-centre, descriptive study. Lancet Infect Dis.
15. Chen, H., J. Guo, C. Wang, F. Luo, X. Yu, W. Zhang, J. Li, D. Zhao, D. Xu, Q. Gong, J. Liao, H. Yang, W. Hou, and Y. Zhang. 2020. Clinical characteristics and intrauterine vertical transmission potential of COVID-19 infection in nine pregnant women: a retrospective review of medical records. Lancet 395: 809-815.
16. Day, M. 2020. Covid-19: ibuprofen should not be used for managing symptoms, say doctors and scientists. BMJ 368: m1086.