Letter: Addressing Gaps in Hospital-Based Hepatitis C Screening—Insights and Recommendations. Authors' Reply'

Abstract

We would like to thank Dr Deng and colleagues for their valuable comments on our recently published work in this Journal [1]. We would like to clarify a few aspects in the light of the hypotheses proposed in their recent commentary [2].

The authors noted that our paper did not adequately address the comorbidities of the 109 patients with a positive hepatitis C (HCV) viral load. For this study, we were able to obtain the ICD-9 discharge codes; however, these may only partially capture the patients' comorbidities and. The association between HCV infection and cardiovascular and metabolic disorders is well-described [3]. However, we believe that patient comorbidities should not serve as a basis for stratifying individuals in an in-hospital screening campaign. Given the excellent safety profile of direct-acting antiviral agents, the presence of significant comorbidities does not substantially limit access to treatment. Moreover, a targeted screening approach is inconsistent with the universal in-hospital screening model we advocate, which seeks to identify the largest possible number of positive patients. This universal approach also has the potential to reduce socio-economic barriers and health inequalities, particularly in Italy, where the public healthcare system could, hopefully in the near future, support its implementation.

Dr Deng and colleagues pointed out that only 17.5% of all hospitalised patients underwent in-hospital screening during the calendar year 2022. We acknowledge that this is a potential limitation in our paper. However, the number of samples collected (n = 11,355) is substantial and provides valuable epidemiological insights. As our study was designed prospectively, it was not possible to retrospectively include unscreened patients, particularly those who declined informed consent. The relatively low percentage of screened patients may likely reflect limited awareness of the issue among both patients and healthcare providers. In this regard, our study can serve as a starting point to raise awareness at multiple levels. The gender differences observed in our study could potentially be attributed to the higher life expectancy of women than of men in Italy, a trend that has remained consistent over the years [4]. Additionally, it is well-established that men have a higher risk of disease progression to cirrhosis, which may explain why liver-related mortality has likely affected more men than women in previous decades [5].

Finally, the authors correctly observed that 61/109 (66%) patients were not treated at our centre. However, this does not necessarily indicate a loss to follow-up. In 15 cases (24.5%), antiviral treatment was postponed due to severe extra-hepatic comorbidities, 7 patients (11.4%) refused to start therapy and 4 (6.5%) died during the same hospitalisation. In only 5 cases (8.1%), the reason for treatment postponement could not be determined. Notably, in the majority of cases (30/61, 49%), patients were referred to local centres, where they successfully initiated therapy. This highlights our hospital's role as a hub centre and underscores the safety and effectiveness of antiviral therapies, which can be administered successfully in peripheral centres. Thus, although we acknowledge the presence of barriers to care for HCV patients at multiple levels [6], these do not apply to the setting described in our study.

Alberto Ferrarese: conceptualization, writing – original draft. Francesco Paolo Russo: conceptualization, supervision, writing – review and editing.

This article is linked to Ferrarese et al papers. To view these articles, visit https://doi.org/10.1111/apt.18433 and https://doi.org/10.1111/apt.18460.