Viral Hepatitis Multi-country Community Screening, Vaccination and Care(VH-COMSAVAC)
Abstract
Since November 2020, a community-centric team of leaders, healthcare providers, including community health workers (CHWs), and researchers has been co-developing the Viral Hepatitis Community Screening, Vaccination, and Care (VH-COMSAVAC) project (and its pilot programme) in Barcelona, Spain. This initiative focuses on prevention, treatment, and management of viral hepatitis infections among migrant and refugee communities coming from countries with a documented high prevalence. This model of care (MoC) includes simplified diagnostic pathways, in which rapid tests and point-of-care blood-sample collection methods are provided in community spaces. It also promotes prevention by offering and providing the hepatitis B virus (HBV) vaccine and an established, expedited, person-centred referral process to specialist care. By decentralising viral hepatitis prevention and care services, and engaging CHWs, this programme helps overcome barriers that migrants and refugees often encounter when engaging with a formal healthcare system.
Introduction
Migrant communities in Catalonia, Spain have partnered with our Barcelona Institute for Global Health (ISGlobal) research team to share perspectives on and experiences with viral hepatitis. These have highlighted deep concerns about HBV-induced liver cancer, and contributed to the development of a community-based MoC to enable early detection and linkage to care.
CHWs have played a central role as part of our team in implementing this MoC, initially serving 400 migrants during the pilot phase of the programme (2020-2022) and later reaching more than 900 migrants (2022-2024) in Catalonia alone. This support has also taken place when the MoC expanded into additional European Union (EU) countries such as Greece and Italy and other parts of Spain, with financial support from the European Commission. Chronic HBV and hepatitis C virus (HCV) infections can lead to chronic liver disease, are responsible for >50% of hepatocellular carcinoma cases globally, and accounted for 1.3 million deaths yearly (2022). Importantly, nearly 80% of people with HBV or HCV remain undiagnosed, which makes efforts to increase diagnosis rates critical in reducing the disease burden.
Who should benefit?
In 2016, the World Health Organization (WHO) called for the elimination of viral hepatitis by 2030. WHO estimates that 304 million people are living with HBV or HCV globally, with 2.2 million new infections occurring annually. Many people from regions with a mid-high prevalence of HBV and HCV are often unaware of their status. This is due to inadequate testing in their home countries, which results from weak healthcare systems facing resource scarcity. The burden of chronic viral hepatitis infections could be dramatically reduced with the promotion of effective prevention and care strategies.
Our ISGlobal team aligned with the World Hepatitis Alliance objective to ‘Find The Missing Millions’ and advanced an aspirational, theoretical, person-centred reframing of this complex public health problem in 2018.‘Find The Missing Millions’ set recommendations for overcoming barriers to diagnosing HBV and HCV and our MoC intended to do that. At the same time, we led the development of the HCV micro-elimination approach. Subsequently, Prof Jeffrey V Lazarus and Dr Camila Picchio designed and scaled up field-based demonstration projects, including VH-COMSAVAC, to provide examples of how to reach, screen, vaccinate, and refer members of at-risk populations to specialist care with which they otherwise would not likely engage.
VH-COMSAVAC facilitates access to prevention and care services for viral hepatitis infections among migrant and refugee populations in Europe. In 2021, the EU received ~2.3 million new migrants, a large proportion of whom were from countries with mid-high incidence and prevalence of viral hepatitis. These migrants often face language, cultural, and legal barriers when accessing and navigating host healthcare systems, as well as systemic racism and discrimination. These challenges can restrict timely diagnoses and worsen related health outcomes.
VH-COMSAVAC delivers viral hepatitis services inclusively and equitably, with the goal of reducing liver-cancer-associated morbidity and mortality in marginalised communities. Simplified prevention, diagnostic, and linkage to care strategies in community settings bring essential healthcare services closer to underserved, at-risk communities. Our CHWs, who are trained members of the migrant community, help provide adequate and culturally sensitive information and services. Overall, VH-COMSAVAC addresses the unmet healthcare needs of migrant and refugee populations in Europe by facilitating engagement with host healthcare systems.
Engagement
This project finds its roots in concerns expressed by a Ghanaian migrant community in Barcelona when members reported new viral hepatitis infections and the imam of their local mosque died due to chronic HBV-induced liver cancer. Dr Daniel Nomah—a medical doctor who is part of the Ghanaian community and was a postgraduate student at ISGlobal at the time—facilitated an introduction between other members and our research group. In response, our coordinator, Dr Camila Picchio and Dr Nomah engaged with other sub-Saharan migrant communities in Catalonia to understand their perspectives on and experiences with HBV. These migrant communities supported the team extensively and contributed to the co-development of an initiative to offer feasible and culturally sensitive prevention and screening opportunities, such as HBV vaccination and rapid testing.
The inclusion of CHWs from these migrant communities has proven pivotal for this MoC, as they have helped overcome barriers, such as cultural and language differences, which can result in misunderstandings. Furthermore, VH-COMSAVAC has engaged with many relevant individuals and communities, allowing us to identify needs and barriers on a rolling basis. To address these issues, project approaches have been continuously tailored. For instance, as some participants have an irregular migratory status and thus lack access to the host healthcare system, we have engaged with the relevant medical authorities and are now able to provide these individuals with expedited access to the public healthcare system. Additionally, participants have often expressed concerns about other health conditions, such as non-communicable diseases like hypertension and type 2 diabetes. Consequently, we have started offering community-based measuring of blood pressure, as well as education sessions on the importance of taking medications as prescribed and engaging with the healthcare system to manage conditions properly. These interventions have allowed us to refer participants to the emergency room where some have been found to have dangerously high blood pressure.
Another part of the project plan is to hold community session days to present study results to the communities themselves. This has been envisioned as an opportunity to return to the same community settings where the interventions have taken place and provide an overview of the overall findings, during which participants could ask further questions for a better understanding of research they have partaken in.
Research
Viral hepatitis infections disproportionally affect migrants from countries with mid-high incidence and prevalence, accounting for an estimated 25% of chronic HBV and 14% of HCV cases in the EU. Effective MoCs targeting these underserved populations must, therefore, be developed. The MoC used in VH-COMSAVAC was created based on the assumption that migrants may be better able to access healthcare if it is provided in culturally and linguistically appropriate ways; many of the barriers they face in engaging with the healthcare system occur at the systemic level.
The design of VH-COMSAVAC’s MoC is centred around the concerns expressed by local migrant communities. Since its inception, our local research group in Barcelona has included CHWs, ensuring constant insight from members of the relevant migrant communities. Throughout the project’s implementation, we have engaged with healthcare professionals to ensure the highest impact on health outcomes of participants. For instance, the research group has always included at least one nurse who is responsible for the community-based clinical interventions. Collaborations with hepatologists have also proven key to providing medical expertise for intervention design and implementation. Moreover, non-governmental organisations have been central to VH-COMSAVAC’s implementation in some study sites (such as Madrid and Milan) where they have been responsible for the recruitment and screening of participants, who are then referred to formal healthcare facilities.
Consequently, since 2020, VH-COMSAVAC has successfully provided viral hepatitis screening and care services to migrant communities, testing >1,900 individuals across Spain, Italy, and Greece, and vaccinating 191 community members against HBV. Overall, 5.9 % and 3.04% tested positive for HBV and HCV, respectively. Importantly, almost 70% of participants had never been tested for these conditions before, even though they belonged to high-risk populations. VH-COMSAVAC has started to close a key gap with respect to the prevalence of viral hepatitis among local migrant communities residing in southern Europe. In the same vein, it has also provided evidence on effective strategies to address this major public health issue.
Finally, the VH-COMSAVAC project has highlighted the importance of shaping healthcare interventions to meet the needs of those who are most vulnerable. To ensure equitable healthcare access, greater efforts must be made to help both those facing difficulties in engaging with traditional systems, as well as those whose medical needs do not necessarily align with those of the general population. To strengthen these findings, VH-COMSAVAC will undertake a comprehensive impact evaluation which includes a value-based assessment and multi-stakeholder consultation, considering patient experience, population health, resource allocation matters, and the welfare of care teams.
