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.

  • People with hepatitis C, or cirrhosis +/- HCC may be currently using injectable drugs and require ongoing access to sterile injecting equipment. Educational resources to assist safer injecting practice when sterile injecting equipment cannot be provided should be available.
  • 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 (and an increased number of 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, if these are available through free government program
  • 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.
  • All people with chronic hepatitis C, including young and well patients should be supported to cease smoking, exercise appropriately, optimise their sleep and adhere to the current national guidelines on alcohol intake(6). 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 SARS-CoV-2 emerged
  • People with substance use disorders might place themselves at greater risk of acquiring SARS-CoV-2  and of legal consequences, seeking to obtain non-prescription drugs.
  • There may be changes in supply of heroin, methamphetamine and other drugs during the SARS-CoV-2 pandemic which may lead to opioid withdrawal, greater demand for access to OST and untoward side-effects of alternative drugs 

There are no data currently available that demonstrate that hepatitis C antiviral medications can prevent infection with SARS-CoV-2. However, people should continue hepatitis C antivirals if they do become infected with COVID-19. 

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

  • 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 excess in 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(7-8). 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(9). There are no current data on outcomes of pregnant women with chronic 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, (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.

Note that recommended measures to protect against SARS-CoV-2 infection may vary between countries, but in all countries 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. 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.asid.net.au/documents/item/1208
  2. Vaduganathan M, Vardeny O, Michel T, McMurray JJV, Pfeffer MA, Solomon SD. Renin-Angiotensin-Aldosterone System Inhibitors in Patients with Covid-19. N Engl J Med. 2020.
  3. Thevarajan I, Buising KL, Cowie B. Clinical presentation and management of COVID-19  https://www.mja.com.au/journal/2020/clinical-presentation-and-management-covid-19. 2020.
  4. Australian guidelines to reduce health risks from drinking alcohol https://www.nhmrc.gov.au/health-advice/alcohol  [
  5. Vaduganathan M, Vardeny O, Michel T, McMurray JJV, Pfeffer MA, Solomon SD. Renin-Angiotensin-Aldosterone System Inhibitors in Patients with Covid-19. N Engl J Med. 2020.
  6. Thomson J, Lin M, Halliday L, Preston G, McIntyre P, Gidding H, et al. Australia's notifiable diseases status, 1998. Annual report of the National Notifiable Diseases Surveillance System. Commun Dis Intell. 1999;23(11):277-305.
  7. Schwartz DA. 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. 2020.
  8. Yu N, Li W, Kang Q, Xiong Z, Wang S, Lin X, et al. 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. 2020.
  9. Chen H, Guo J, Wang C, Luo F, Yu X, Zhang W, et al. Clinical characteristics and intrauterine vertical transmission potential of COVID-19 infection in nine pregnant women: a retrospective review of medical records. Lancet. 2020;395(10226):809-15.
  10. Day, M. 2020. Covid-19: ibuprofen should not be used for managing symptoms, say doctors and scientists. BMJ 368: m1086.