key: cord-0749388-l0p8xv6i authors: Binka, Mawuena; Bartlett, Sofia; Velásquez García, Héctor A.; Darvishian, Maryam; Jeong, Dahn; Adu, Prince; Alvarez, Maria; Wong, Stanley; Yu, Amanda; Samji, Hasina; Krajden, Mel; Wong, Jason; Janjua, Naveed Z. title: Impact of COVID‐19‐related public health measures on HCV testing in British Columbia, Canada: An interrupted time series analysis date: 2021-10-13 journal: Liver Int DOI: 10.1111/liv.15074 sha: 26f2700a72ee6ed30569ddc60bf6c5f1b07850cd doc_id: 749388 cord_uid: l0p8xv6i BACKGROUND & AIMS: Public health measures introduced to limit transmission of severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2), which causes coronavirus disease 2019 (COVID‐19), also disrupted various healthcare services in many regions worldwide, including British Columbia (BC), Canada. We assessed the impact of these measures, first introduced in BC in March 2020, on hepatitis C (HCV) testing and first‐time HCV‐positive diagnoses within the province. METHODS: De‐identified HCV testing data for BC residents were obtained from the provincial Public Health Laboratory. Weekly changes in anti‐HCV, HCV RNA and genotype testing episodes and first‐time HCV‐positive (anti‐HCV/RNA/genotype) diagnoses from January 2018 to December 2020 were assessed and associations were determined using segmented regression models examining rates before vs after calendar week 12 of 2020, when measures were introduced. RESULTS: Average weekly HCV testing and first‐time HCV‐positive diagnosis rates fell immediately following the imposition of public health measures by 62.3 per 100 000 population and 2.9 episodes per 1 000 000 population, respectively (P < .0001 for both), and recovered in subsequent weeks to near pre‐March 2020 levels. Average weekly anti‐HCV positivity rates decreased steadily pre‐restrictions and this trend remained unchanged afterwards. CONCLUSIONS: Reductions in HCV testing and first‐time HCV‐positive diagnosis rates, key drivers of progression along the HCV care cascade, occurred following the introduction of COVID‐19‐related public health measures. Further assessment will be required to better understand the full impact of these service disruptions on the HCV care cascade and to inform strategies for the re‐engagement of people who may have been lost to care because of these measures. In 2016, Canada, alongside other World Health Organization (WHO) member states, committed to eliminating the threat that hepatitis C virus (HCV) poses to public health worldwide by 2030. 1 To that end, many member states have implemented policies and strategies to facilitate the attainment of the disease prevention, healthcare provision and mortality-reduction goals that form the cornerstone of this Global Health Sector Strategy. [1] [2] [3] Canada is making significant progress towards meeting the 2030 elimination goals, with the provision of unrestricted access to publicly funded therapy for persons with chronic HCV infection and elimination efforts being initiated in many provinces, including British Columbia (BC). [4] [5] [6] Testing is a key component of these efforts, and is the first step to engaging people living with HCV into care. 7 The emergence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in late 2019 led to the implementation of broad public health measures to prevent and control transmission of the virus and to preserve healthcare resources in many countries across the world, including Canada. [8] [9] [10] [11] [12] [13] [14] These measures have had sweeping economic, social and health-related impacts globally, including the disruption of healthcare services such as HCV prevention, testing, treatment and post-treatment follow-up. [15] [16] [17] Many people living with HCV have concurrent substance use or mental health challenges, are socially and materially deprived, and living with HIV or HBV co-infection. 18, 19 Thus, given the syndemic nature of HCV infection, these service disruptions may have more profound short-and long-term impacts within these groups. Furthermore, HCV-related service disruptions could delay Canada's progression towards the achievement of the viral hepatitis elimination goals. In this study, the impact of COVID-19-related public health measures on HCV testing and first-time HCV-positive diagnoses within the province were assessed using population-level laboratory data as a first step towards understanding the potential impact of healthcare service disruptions on BC's HCV elimination efforts. De-identified HCV testing data for BC residents were obtained from the BCCDC PHL, which performs over 95% of anti-HCV (antibody) screening and all confirmatory anti-HCV, RNA testing and genotyping in BC. All positive, negative and indeterminate testing episodes were included in this analysis, and testing outcomes were comprised of the integrated test results for each test type Testing is essential for progression along the HCV care cascade. In this interrupted time series analysis, the introduction of COVID-19-related public health measures in March 2020 was associated with large declines in mean weekly HCV testing and diagnosis rates in British Columbia. Persons living with HCV who may have been lost to care after public health measures were introduced should be reengaged with care for improved health outcomes and to support progression towards HCV elimination within the province. progression towards clearing the virus, although differentiating between spontaneous clearance and sustained virologic response (SVR) was not possible, as we did not have access to treatment data. The study period began on January 1, 2018 and ended on December 31, 2020. An interrupted time series study design was adopted, using segmented regression models [25] [26] [27] where Y t represents the outcome of interest (HCV testing, first-time HCV-positive and first-time HCV RNA-negative rates) in week t; β 0 , the baseline mean weekly outcome rate before public health measures (restrictions) were imposed; β 1 , the mean weekly change in outcome rates (slope) before public health measures were imposed; T, the time in calendar weeks beginning on January 1, 2018; β 2 , the change in the level of outcome rates once public health measures were imposed; X, the dummy variable marking the period before (0) and after (1) restrictions were imposed; β 3 , the difference in slope (change in mean weekly outcome rates) after vs before public health measures were imposed; Z, the time (in weeks) post-restrictions; and ν, random variability in F I G U R E 1 Weekly HCV testing rates in British Columbia, 2018-2020. A, All HCV tests, (B) anti-HCV tests, (C) HCV RNA tests, (D) HCV genotyping tests. HCV, hepatitis C virus; RNA, ribonucleic acid the model adjusted for autocorrelation with the maximum likelihood method. Estimated rate and estimated mean rate (trend) values from the autocorrelation-corrected regression models were also generated with the AUTOREG procedure in SAS 9.4.28,29 The final parameters for inclusion in the model were determined using a stepwise backward elimination approach. 25, 28 Autocorrelation was assessed with Durbin-Watson tests. Data preparation and visualization was done using R statistical software (version 3.5.2), 30 while data analysis was done with SAS (version 9.4).29 Statistical significance was defined as P < .05. This study was performed under the public health surveillance mandate of the BCCDC and did not require approval from an ethical review board. Estimated mean weekly HCV testing rates in BC were stable at approximately 124.6 HCV tests per 100 000 population per week prior to the introduction of COVID-19-related public health measures in calendar week 12 of 2020 ( Figure 1A , Table 1 ). This overall trend was driven by anti-HCV testing, which formed the majority of HCV testing done in BC ( Figure 1B ). In contrast, estimated mean weekly HCV RNA testing and HCV genotyping rates fell steadily within this timeframe (P < .0001 for both) ( Figure 1C ,D, Table 1 +0.09 tests per 1 000 000 population, P < .05) ( Table 1 ). There was a slight shift in HCV testing towards females and persons aged 30 to 39 years once COVID-19-related restrictions were implemented (Supplementary Table S1 ). Estimated mean weekly first-time HCV-positive diagnosis rates per 1 000 000 population followed a pattern matching that of average weekly HCV RNA and genotype testing rates: declining gradually prior to 2020, falling rapidly after COVID- 19 Table S2 ). To estimate trends in progression towards clearing the virus, either spontaneously or following treatment, we assessed the proportion of mean weekly first-time HCV RNA-negative tests following a firsttime HCV-positive diagnosis as a percentage of mean weekly HCV RNA tests. Prior to calendar week 12 of 2020, there was a gradual but statistically non-significant increase in the mean weekly percentage of first-time HCV RNA-negative tests following a first-time HCV-positive diagnosis (P = .12) ( Figure 3 , Table 2 ). These average weekly testing rates dropped slightly as public health measures came into effect in calendar week 12 of 2020 (P = .68) and continued to decline steadily until the end of 2020. Despite the reversal in trend following week 12 of 2020, the difference in the rate of change in mean weekly percentage of first-time HCV RNA-negative tests (slope of the curve) post-vs pre-restrictions was not statistically significant (P = .21) (Figure 3 , Table 2 ). In this study, we describe the impact of public health measures to Failure to do so may undermine the progress that has been made in HCV care provincially and prevent BC from eliminating HCV as a threat to public health by 2030. This study was performed under the public health surveillance mandate of the BCCDC and did not require approval from an ethical review board. All inferences, opinions and conclusions drawn in this publication are those of the authors, and do not necessarily reflect the opinions or policies of the Data Steward(s). We gratefully acknowledge the residents of British Columbia who are represented in the BCCDC Public Health Laboratory database, and for whom this work is intended to benefit. MK has received grant/research support from Roche, Merck, Siemens, Boeringer Ingelheim and Hologic, Inc. SB has spoken and consulted for Gilead Sciences Canada Inc and AbbVie Canada. The remaining authors have no conflicts of interest to declare. 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