Background

Epidemiology of HCV and HBV in the province of Brescia.

The global eradication of HCV proposed by the World Health Organization (WHO) by 2030 is an objective being pursued through every possible means [1]. An effective and safe therapy is now available to treat HCV infection. The province of Brescia faces a huge epidemiological situation, with the prevalence of HCV and HBV infection reaching up to 3.0% in some areas. One of the most apparent damages caused by the interruption of outpatient and hospital services during the COVID pandemic has been the increase in HCV/HBV-related hepatocellular carcinomas due to missed screening and ultrasound monitoring [2]. In the province of Brescia, nearly the entire population chronically infected with HCV, followed in the clinical departments of infectious diseases, hepatology, and gastroenterology, has already undergone eradication therapy.

However, it is estimated that there are still many unidentified patients with HCV hepatitis, and strategies for identification the uncovering submerged pathology are deemed necessary. Facing this epidemiological condition, the MISI Foundation (Infectious Diseases and International Health Foundation) and FdS E.T.S (Il Filo della Salute E.T.S, non-profit third-sector organization, have consistently worked to promote initiatives to bring HCV cases to the forefront in the Brescia territory.

Previous projects in the Brescia area and the obtained results.

Between December 2020 and March 2021, the pilot phase of the HELP DESK HCV screening initiative took place during the COVID-19 wave, involving two pharmacies. Despite resource limitations, it was possible to test 500 individuals, identifying 15 HCV Ab-positive persons, of whom 8 were active carriers of the virus (HCV-RNA positive). Infected patients were addressed to HCV treatment centers most convenient for their residential area and underwent appropriate treatment.

Given the success of the pilot phase and based on international experiences of screening campaign [3-8], the MISI Foundation has proposed a PHASE 2.0, introducing a help desk on COVID-19 Vaccines, and Hepatitis facilities. The service is advertised in all pharmacies in the town of Brescia and its province. Interested individuals could call a hotline, where a free telephone counseling session was organized to address their questions. During the conversation, a risk assessment for HCV is conducted using the C-now hepatitis app, and the option of undergoing a rapid HCV test is offered. In the event of a positive result, the patient is then addressed to the appropriate treatment centers for further care.

Focus on HCV: Target Population and Predisposing Factors.

Worldwide, between the regions most affected by HCV are classified Eastern Europe and Balkans, with a prevalence reaching >3% [9,19]. The settled migrant population from these areas is highly represented in the Brescia province, This population is often diagnosed late with chronic hepatitis. ESLD or HCC often exhibit multifactorial causes, driven not only by undiagnosed viral infection but also by alcohol use/abuse, diet, obesity, and diabetes. Most of settled migrants f in the town of Brescia, primarily include women employed as domestic workers and caregivers. These persons often neglect their disease, refuse health check-ups, and, often, return to their home country for medical care. These individuals are frequently obese and predisposed to metabolic syndrome.

Comorbidities associated with chronic HCV infection, such as hepatic steatosis and diabetes, are exacerbated by factors such as a diet rich in sugars and fats and alcohol abuse. The frequency of ESLD and HCC is higher in this population compared to the Italian population due to the multifactorial nature related to ethnicity and behavioral factors.

Demography of the Foreign Resident Population in Brescia

Demography of the Foreign Resident Population in Brescia as of January 1, 2020, include 151,820 individuals, constituting 12.1% of the global resident population. The largest foreign community is from Romania, representing 16.4% of all foreigners in the area, followed by Albania (11.3%) [11]. The purpose to develop a project for the detection of submerged infections by HCV/HBV/HDV in a population of individuals from Eastern European countries permanently residing in Brescia is based on two main factors:

1) Likely high prevalence based on epidemiological data and age group.

2) The sample is easily identifiable and accessible through recruitment agencies, word of mouth within the group itself, or by identifying a suitable “influencer” for the target population.

In (Figure 1) and (Table 1) are described the updated ISTAT (National Institute of Statistics.) data on the percentages of individuals from Eastern Europe permanently residing in Brescia.

Figure 1: Trend of foreign citizens in Brescia province (ISTAT 2020).

Table 1: Updated ISTAT (National Institute of Statistics) data on the percentage of people coming from Eastern Europe in a permanent basis in Brescia.

Since 2020, the following populations reside in the Brescia area: 27,174 males and 63,188 females from Eastern Europe

The prevalence of HCV and/or HBV in Eastern European countries is estimated at 3.3%. Therefore, it is estimated that: 2,085 females and 896 males from Eastern Europe, subjects of the present project, may be carriers of Hepatitis C and/or B [1].

As expected results: 16 infections could be identified per 500 tested females.

If the test were reserved for patients with risk triggers, in addition to the country of prevalence (triggers identified with the “C-now hepatitis” web app or mobile app available on Google store Apple or on www.fondazionemisi.it)), there could be an imagined increase of 2% in positives. The anticipated obstacles for enlisting subjects were limited sensitivity to prevention and the performance of blood tests and tendency to seek healthcare in their home country due to potential access difficulties in host country. However, the existence of a project that connects this target population with specialist centers could have advantages for linkage-to-care, not only for liver disease but also for other health issues that may emerge during a consultation and could be diagnosed and treated, was presumed to be attractive in convincing subjects to participate.

Aims

The main objectives of the project were the Identification of the target population at risk of HBV/HCV infections, expand screening programs and promote the detection of potential HCV related diseases, directing them to specialized treatment facilities in line with WHO objectives to promote the elimination of HCV infection at the national level.

Methods

The project lasted for nine months (October 2022 – June 2023) and included 2 phases: Preliminary phase: Identification of suitable facilities within the province of Brescia for recruiting the target population of settled migrants from Eastern Europe. Identification and assessment of potential limitations, including linguistic and cultural barriers. Subsequent involvement of interpreters or key “influencers” for the target population. Design and creation of multilingual informational material for comprehensive and tailored outreach to the various identified locations (Russian, Romanian, Ukrainian, etc.).

Recruitment and Testing Phase : Active recruitment in the identified facilities offering Pre-test counseling; opportunity for rapid auto testing for HBV and HCV ,linkage to care for individuals testing positive for HCV, including HCV RNA testing, and testing for HDV in individuals positive for HBsAg and flyers (Figure 2AB).

Figure 2AB: Project’s phases; A: Preliminary phase; B: Recruitment and Testing Phase.

Results

Identification of structures suitable for reaching the target population, The structures, such as caregiver and housekeeping recruitment agencies, were analyzed to assess the types of individuals accessing their services to look for/search for employment. Following this investigation, which involved ten structures, two leading agencies were identified in the area: Family Care ® and Private Assistance ® (Garda and Valtanesi territory)

These two agencies exhibit the following characteristics:

• Address 80% of the demand for housekeepers and caregivers in the area
• Have in-depth knowledge of the target population’s characteristics
• Have developed communication methods tailored to the different nationality
• Have devised campaigns suitable for attracting the correct population based on family needs

The communication management approach, work ethics, and the number of users handled led us to choose these two companies as project partners, involving them in all planning and implementation steps. Identification of the most effective communication methods for the service and assessment of potential limitations with the assistance of the identified structures, analysis were conducted on the types of products and language to engage the target population with the counselling and HCV/ HBV screening services provided by the project. 4 types of “personas” representing the most significant groups within the target population, were identified incorporating a type that was not initially foreseen: caregivers from South America. Analysis on type of flyers, language and content were conducted.

Four type of “personas” representing the most prominent groups in the target population, were identified: Caregivers from Moldavia, Ukraine, Russia and South America. Additionaly, individuals who could serve as “influencers” within the four groups were identified and acted as promoters, posting messages on social media channels to invite their followers to join the project.

Design and implementation of multilingual informative material and social media supports Activities managed by the MCO International team following jointly developed guidelines. Flyer, posters and digital structures/activities (A Facebook page tailored to the need and targeted communication campaign for the local population) were producted. Flyers were created and translated into Spanish, Moldovan, Ukrainian, and Russian languages (Figure 3). The flyers were distributed in places frequented by individuals from the target groups (public gardens, bars, shopping centers, supermarkets, etc.). It was assumed that word of mouth could be a valid method to make the project known.

Figure 3: Flyers were created and distributed in places frequented by individuals from the target groups (Public gardens, bars, shopping centres, supermarkets, etc.)

Identification of testing facilities Various delivery methods for counseling and tests were identified and pursued once the user expresses interest in participating in the examined (?) project: At recruitment agencies of Family Care (Brescia) or Private Assistance (Desenzano/Garda); at the Filo della Salute offices in Brescia and Padenghe sul Garda, at the private outdoor clinic (OPD) (POLIAMBULATORIO OBERDAN®).

In all these locations, the operator/counselor/physician conducted a comprehensive patient examination, including a complete medical history, and performed pre-test counseling. The patient was encouraged to undergo a rapid self-test for HCVAb (Ora Quick Rapid antibody test®-HCV Ora Sure Technologies, Inc.220EstFirst Street Bethlehem, PA 18015 USA) and for HBs Ag (RightSign HBsAg Rapid Test Cassette (Serum/Plasma) Distributor nal von minden GmBH Carl- Zeiss Str 12,47445 Moers)

In the case of a positive HCV Ab or HBsAg test result, a post test counselling were performed and linkage to care was established at the nearest and convenient hepatological or infectious disease care facility. If another clinically significant condition was identified, linkage to care was proposed at the most suitable specialized facility studied population Risk factors. Three hundred and fifty individuals were tested: 300 women and 50 men, with an average age of 47 years (range 40-68). In (Table 2) are described the characetistics and the outcome of the testing phase. Thirty percent reported occasional alcohol use, and 10% reported smoking at least 10 cigarettes per day. Comorbidities identified included obesity (BMI > 30) in 70% of the sample, 55% reported taking medication for hypertension, known cardiac disorders/ trouble were present in 10%, diabetes therapy was reported in 30% of the sample, and 70% reported arthralgia. Twenty-five percent of the subjects reported taking more than three medications daily.

Table 2: Sociodemographic and clinic characteristics of the studied population and results of HCVa nd HBV auto test.