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The COVID-19 pandemic:
A unique opportunity to
re-evaluate liver disease care
Graham R Foster (UK)
Ivan Gardini (Italy)
This meeting was organised and funded by Gilead Sciences Europe Ltd.
Date of preparation: September 2020. IHQ-LVD-2020-09-0002 © 2020 Gilead Sciences Europe Ltd.
Disclosures Graham R Foster • Speaker and consultancy fees from AbbVie, Gilead Sciences, GlaxoSmithKline, Merck Sharp & Dohme, Shionogi, Springbank Ivan Gardini • EpaC Onlus has received grants from Gilead Sciences, AbbVie, AlfaSigma, Intercept and Merck Sharp & Dohme
The COVID-19 pandemic:
A unique opportunity to re-evaluate
liver disease care
Graham R Foster
Professor of Hepatology
Queen Mary, University of London
A new virus in the mix: A huge global impact
Dec 2019–Aug 2020
~22 million
cases globally*
*As of 20 August 2020.
European Centre for Disease Prevention and Control. COVID-19 situation
update worldwide, as of 19 August 2020.
Available at: https://www.ecdc.europa.eu/en/geographical-distribution-
2019-ncov-cases (accessed August 2020)
A population with liver disease/cirrhosis at
direct increased risk
Cirrhosis/COVID-19 registry data (14 July 2020)2
Major outcomes in patients with chronic liver disease
Non-cirrhotic Cirrhosis
1.5 billion (n=372) (n=425)
people were estimated to Intensive care admission 68 (18%) 117 (28%)
chronic liver
have Invasive ventilation 64 (17%) 79 (19%)
diseases in 2017 1 Death 27 (7%) 137 (32%)
1. Moon AM, et al. Clin Gastroenterol Hepatol 2019;doi: 10.1016/j.cgh.2019.07.060;
2. COVID-HEP registry. Weekly update thirteen – 14 July 2020.
Available at: https://www.covid-hep.net/updates.html (accessed August 2020)
A population with liver disease/cirrhosis at
indirect increased risk
Alcohol
1.5 billion
people were estimated to Exacerbated
chronic liver
have by COVID-19
diseases in 2017 1
Late
presentation
of HCC
1. Moon AM, et al. Clin Gastroenterol Hepatol 2019;doi: 10.1016/j.cgh.2019.07.060 HCC: hepatocellular carcinomaAre real-world observations a sign of things to come?
Number of cancer cases* per week
80 2500
Cases from central pathology laboratory
Tertiary hospital
70
2000
Cases from tertiary hospital
60
Central pathology laboratory
50
1500
40
1000
30
20
500
10
0 0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26
Jan 2020 Weeks
Unpublished data courtesy of Marc Bourlière *Malignancies of all types (including breast, lung, renal, liver)A change to liver disease care
Lockdowns and interim changes to healthcare services were implemented to increase capacity for
COVID-19 and to help flatten the curve
Patient fear1
Number of cases
Closures1
• Primary care settings/GP clinics
• Harm reduction centres
Liver disease management
Cancelled, delayed or postponed
No procedures2
intervention • Blood draws
• Liver transplantation
• Liver biopsy
Intervention • Endoscopy
• HCC surveillance
Time since first case
1. Pawlotsky JM. Nat Rev Gastroenterol Hepatol 2020;1–3. doi: 10.1038/s41575-020-0328-2;
2. Bollipo S, et al. Gut 2020;69:1369–372A change to liver disease care
Lockdowns and interim changes to healthcare services were implemented to increase capacity for
COVID-19 and to help flatten the curve
Patient fear1
What will be the immediate impact of these
Closuresfactors on liver
Number of cases
1
• Primary care settings/GP clinics
disease services beyond COVID-19?
• Harm reduction centres
Impact liver disease
management Cancelled, delayed or postponed
No procedures2
intervention • Blood draws
• Liver transplantation
• Liver biopsy
Intervention • Endoscopy
• HCC surveillance
Time since first case
1. Pawlotsky JM. Nat Rev Gastroenterol Hepatol 2020;1–3. doi: 10.1038/s41575-020-0328-2;
2. Bollipo S, et al. Gut 2020;69:1369–372In-patient hospital care: The long-term impact of
COVID-19 on hospital care is not yet clear
The impact of COVID-19 on liver mortality remains unclear
Anecdotes of …..
Late presentation of disease (particularly alcohol)
Severe malnutrition
Advanced malignancy
BUT….
Service reconfiguration to deal with COVID-19 and
increased ITU/HDU capacity has led to revised ways
of working
Foster G, personal perspective ITU/HDH: Intensive Therapy Unit/High Dependency UnitOut-patient services will need to be reconfigured
to allow safe care to resume
Consider
assessment tools Simplify
used – assessments
TE vs NITs
Decentralise blood tests and
imaging procedures Increase capacity
Embed telemedicine/telehealth
Minimise exposure
to COVID-19
Prioritise visits – review clinic backlog and
schedule patients based on disease severity and HCC screening
clinical need
Bollipo S, et al. Gut 2020;69:1369–372 NIT: noninvasive test; TE: transient elastographyOut-patient models of care
GP referral
Treatment Speciality
Choose and Blood test at hospital assessment clinic clinic
CURRENT
Community referrals book/electronic referral
FibroScan appointment at hospital
Consultant referral Seen in OPD
Reviewed in clinic General
Ward discharge Scan appointment at hospital
Letter/
with results liver clinic
Email
Emergency referral ED attendance
Discharged
GP referral Specialty
Established diagnosis
(urgent and routine) Referral clinic
template
Daily Established diagnosis Return to GP with advice Virtual by
Community referral Referral portal consultant default (option
requiring advice and guidance and guidance
NEW
triage for F2F if
needed,
Algorithm informs Advise additional test
Consultant referral consultant review Inadequate information estimate 30%)
and re-refer
Cerner (phone for
emergencies)
FibroScan
Ward discharge One-stop Ultrasound scan
Diagnostic uncertainty
clinic Consultant review
Emergency referral Discharged
Ultrasound scan
Hot Jaundice pathway
ED: emergency department; F2F: face-to-face; OPD: outpatient department Ambulatory liver
clinic
Foster G, personal communication Consultant reviewOut-patient models of care
GP referral
Treatment Speciality
Choose and Blood test at hospital assessment clinic clinic
CURRENT
Community referrals book/electronic referral
Multiple entry systems
Consultant referral Seen in OPD Multiple contacts
FibroScan appointment at hospital All consultations
Trust specific
prior to decision Reviewed in clinic F2F General
Ward discharge
Origin specific Letter/
Scan appointment at hospital with results liver clinic
Email
Emergency referral ED attendance
Discharged
GP referral Specialty
Established diagnosis
(urgent and routine) Referral clinic
template
Daily Established diagnosis Return to GP with advice Virtual by
Community referral Referral portal consultant default (option
requiring advice and guidance and guidance
NEW
triage for F2F if
needed,
Advise additional test
Consultant referral
Algorithm informs
consultant review Inadequate information
and re-refer Reduced
estimate 30%)
Single point Streamlined
Cerner (phone for
emergencies)
unnecessary F2F
of access decision making FibroScan
Ultrasoundencounters
Ward discharge One-stop
Diagnostic uncertainty scan
clinic Consultant review
Emergency referral Discharged
Ultrasound scan
Hot Jaundice pathway
ED: emergency department; F2F: face-to-face; OPD: outpatient department Ambulatory liver
clinic
Foster G, personal communication Consultant reviewOutreach services will need to regain lost ground
Maintaining momentum in
screening and linkage to care
activities – think outside the box! WHO
viral hepatitis elimination
WHO: World Health OrganizationOutreach services will need to regain
lost ground
Housed in
London 1300 All being
people hotels tested and
who are and given a treated for
homeless phone HCV
London outreach over 6 weeks
600 516
500
Number
400
300
200
100 46 41 24 11 6 2
0
Hotel testing
Hotel testing events
events Number Tests
Tests Number
HCVHCV
Ab+AB+ HCV
HCV +
RNA+ Treatment
Treatmentstart on
start HIV
HIV++ HBV+
HBV+
day
on day
Personal communication, Rachel Halford; Data courtesy of The Hepatitis C Trust Ab: antibody; RNA: ribonucleic acidRe-configuring liver disease care
Ivan Gardini
President of EpaC Onlus, ItalyRe-configuring liver disease care
Which services can be deferred?
Decisions made solely by policymakers
Which services cannot be deferred/must could lead to fragmentation
be carried out without delay?
Challenge
Policymakers
Local scientific societies
EASL National
recommendations Regional
Local patient organisations
Solution Local
Once it has been established which services are deferrable, it will be easier to determine:
• Which services can (or must) be transferred to other locations (outside the hospital)
• What tools could be used to help deliver health services (e.g. telemedicine)
• Each country will have to adopt different tools and methods that are compatible with their local healthcare system
Next steps • Where patient organisations can carry out appropriate advocacy activities
Gardini I, personal perspective EASL: European Association for the Study of the LiverRe-configuring liver disease care
What is the current situation with regards to prioritisation of liver disease care services?
In June 2020, EASL, in collaboration with ESCMID, released a
position paper on the care of patients with liver disease during
the COVID-19 pandemic
This position paper aimed to:
• Define prioritisation criteria for outpatient care
• Provide specific considerations for different patient cohorts
An update was published in August 2020 which provided some
recommendations for returning to routine care
Boettler T, et al. JHEP Rep 2020;2:100113. doi: 10.1016/j.jhepr.2020.100113;
Boettler T, et al. JHEP Rep 2020;doi.org/10.1016/j.jhepr.2020.100169 ESCMID: European Society of Clinical Microbiology and Infectious DiseasesA new virus in the mix:
A chance to re-imagine liver disease care
We are in a
The liver disease But remember:
unique position Should we return We must be
community has a ‘one size’ approach
to re-evaluate to the status quo? prepared for a
responded quickly will not fit all
liver disease care second peak…You can also read
