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Article

Hepatitis C Virus Opportunistic Screening in South-Eastern Tuscany Residents Admitted to the University Hospital in Siena

by
Cristina Stasi
1,2,*,
Tommaso Marzotti
1,
Filippo Nassi
1,
Giovanna Giugliano
1,
Sabrina Pacini
1,
Silvia Rentini
3,
Riccardo Accioli
1,
Raffaele Macchiarelli
3,
Luigi Gennari
1,
Pietro Enea Lazzerini
1 and
Stefano Brillanti
1 on behalf of Le Scotte HCV Screening Group
1
Department of Medical, Surgical and Neuroscience Sciences, University of Siena, 53100 Siena, Italy
2
Department of Life Science, Health, and Health Professions, Link Campus University, 00165 Roma, Italy
3
Gastroenterology and Operational Endoscopy Unit, A.O.U.S. Policlinico S. Maria alle Scotte, 53100 Siena, Italy
*
Author to whom correspondence should be addressed.
Livers 2025, 5(3), 30; https://doi.org/10.3390/livers5030030
Submission received: 12 May 2025 / Revised: 18 June 2025 / Accepted: 26 June 2025 / Published: 30 June 2025
(This article belongs to the Special Issue The Surveillance, Prevention, and Treatment of Viral Hepatitis: Looking Forward to Global Elimination)
Browse Figure
Versions Notes

Abstract

Background. To meet the WHO’s viral hepatitis elimination goal by 2030, the Minister of Health (Italy) introduced free HCV screening among people born between 1969 and 1989 and those at greater risk (people in the care of the addiction services and detained). Aims. To estimate the following: (i) the prevalence of HCV in hospitalized patients born before 1969 not included in the free HCV screening, (ii) the prevalence of transaminase values outside the range, and (iii) the HBV prevalence in a subgroup of patients. Methods. Anti-HCV antibodies and transaminase values were prospectively evaluated in patients born before 1969 and admitted to the Santa Maria alle Scotte Hospital in Siena. The first screening (October 2021–July 2022) was conducted in the Internal Medicine Division (cohort 0), and the second one (May 2024–October 2024) in Internal Medicine, Gastroenterology, and Geriatric Units (cohorts 1–3), including clinical features and HBV markers in a subgroup of patients. Results. Overall, 774 subjects underwent HCV screening. In the first screening period, 1.4% (8/567) of patients were anti-HCV+, of whom 0.7% were HCV RNA+ (4/567). In the second, 3.9% of patients (8/207) were anti-HCV+ and 0.9% were viremic (2/207). Overall, HCV prevalence was 0.8%. Of 96 patients in the gastroenterology cohort, 8 patients were at risk for occult HBV infection (8.3%). Conclusions. Our study demonstrates a chronic HCV infection prevalence of 0.8% in hospitalised patients born before 1969 and a prevalence of 8.3% of people at risk for occult HBV infection in a subgroup of patients residing in South-Eastern Tuscany, confirming that an opportunistic screening can identify the unrecognized people affected by viral hepatitis.

1. Introduction

Worldwide, chronic viral hepatitis is among the principal public health problems. Currently, one of the main objectives of the World Health Organization (WHO) is the eradication of viral hepatitis by 2030 (90% reduction in infections and 65% in mortality by 2030) [1], with the final goal of identifying undiagnosed individuals with chronic hepatitis C virus (HCV) infection before clinical progression of liver disease.
With the advent of direct-acting antiviral agents (DAAs), sustained virologic response (SVR) rates in HCV-infected patients ranged between 95% and 99%. These results have dramatically changed the management of chronic HCV infection, with great interest from public health organisations in terms of HCV elimination [2].
In 2017, only nine countries were on track to meet the WHO’s HCV elimination targets by 2030 [3]. The COVID-19 pandemic has further reduced screening and identification programs for HCV-infected individuals, resulting in a marked reduction in linkage to care of patients with HCV. According to data from the WHO, in 2022, 50 million people in the world were living with chronic HCV infection, which resulted in approximately 242,000 deaths each year. In 2022, still only 36% of the people living with HCV knew their diagnosis, while 20% (12.5 million) of those diagnosed had been treated [4]. The unrecognized people are represented both by all subjects affected by HCV who are not aware of their condition, and by those diagnosed with HCV but not yet treated. It must also consider patients who underwent treatment but were not cured and have been reinfected, even if this is a low percentage. Reinfection rates are generally low but can be higher in individuals at greater risk, such as via injection drug use [5,6].
Expanding early HCV diagnosis requires practical diagnostic approaches, and a linkage to care and treatment services [7]. According to estimates of HCV infection in Italy published by Kondili et al. [8], as of 1 January 2021, there are approximately 400,000 people with active HCV infection (prevalence 0.66%), of which ≈290,000 have a stage of fibrosis from none to severe (F0–F3) and are, therefore, potentially asymptomatic (prevalence 0.48%). Few epidemiological studies have been conducted nationwide to estimate the candidates for eradication treatment.
The epidemiological study by Andriulli et al. [9] found an anti-HCV prevalence of 2.3% in Italy, showing a significant peak prevalence (7.0%) in people born between 1935 and 1944.
Following the law 8/2020, which establishes the activation of free HCV screening for people born between 1969 and 1989, for subjects in the care of the addiction services (Ser.D) and detained people [10], the Tuscany Region, after having activated free screening among two of the groups envisaged by the ministerial decree (citizens who have access to addiction services and prisoners), started the screening campaign aimed at the other cohort of the population, i.e., all citizens resident in Tuscany born between 1969 and 1989 [11].
Our project was in line with both the regional screening plans by the Tuscany Region for the identification of unknown and asymptomatic cases of subjects with HCV and the broader national plan for HCV elimination from the Ministry of Health.
Based on these premises, the objectives of the present study were as follows:
(i) identifying HCV infection in patients hospitalised in the Medicine and Surgery Departments of the Santa Maria alle Scotte Hospital in Siena, without a history of HCV, by carrying out the anti-HCV test (serological analysis),
(ii) estimating the prevalence of HCV infection in patients born before 1969 excluded from the free HCV screening, and the number of patients with transaminase (aspartate aminotransferase [AST] and alanine aminotransferase [ALT]) values out of range,
(iii) evaluating the prevalence of hepatitis B virus (HBV) in a subgroup of patients.

2. Patients and Methods

2.1. Study Design

The present study project has included a test for anti-HCV antibodies among the tests requested from all patients capable of providing consent, born before 1969 and hospitalised in the medical-surgical (Medicine and Gastroenterology) areas.
Therefore, this screening project for all subjects born before 1969 comes alongside the free screening for HCV provided for by the “Milleproroghe” ministerial decree and indirectly aims to raise awareness among hospital physicians not directly involved in the care of patients affected by HCV. Given that hospital admissions are diversified based on the admission diagnosis in the departments involved, and the screening occurred at different times within the same study protocol, four cohorts were considered. The first screening study occurred between October 2021 and July 2022, involving patients admitted to the Internal Medicine (cohort 0, including 567 patients). To evaluate the trend in HCV infection, the second period of screening occurred between May 2024 and October 2024, involving three different cohorts of patients admitted to the Internal and Complex Medicine Unit (cohort 1, including 63 patients), Gastroenterology and Operative Endoscopy Unit (cohort 2, including 96 patients), and Internal Medicine and Geriatrics Unit (cohort 3, including 48 patients). In the later three cohorts, we further investigated the clinical characteristics of patients.
In cohort 2 (n = 96), the study also involved the determination of hepatitis B markers during ordinary hospitalisation. The patients were subjected to a single blood sample per patient, and there was no provision for conservation of the biological material after the blood tests for anti-HCV and hepatitis B markers. Laboratory tests were performed during hospitalization. Physicians warned patients about the possibility of transmission of the infection and existing treatment options.
The inclusion criteria were as follows:
-
Age: any patient born before 1 January 1969.
-
Hospitalisation status: any patient admitted to hospital, regardless of the specific cause leading to hospitalisation.
-
Willingness to provide free and informed consent.
The exclusion criteria were as follows:
-
Impossibility of providing free and voluntary informed consent,
-
Prior diagnosis of HCV.
The study was approved by the local Ethics Committee (Prot. N. 20554)

2.2. Opportunistic Screening and Linkage to Care

After obtaining informed consent, a venous blood sample was performed to test for positivity for anti-HCV antibodies (Alinity Anti-HCV Reagent Kit from Abbott has a cutoff of 1.00 signal-to-cutoff ratio) in all patients, as well as hepatitis B markers (Hepatitis B surface antigen [HBsAg], hepatitis B core antibody [anti-HBc], and hepatitis B surface antibody [anti-HBs]) in cohort 2. The Alinity Anti-HBs Reagent Kit from Abbott (range for the measuring interval is 2.00 mIU/mL to 1000.00 mIU/mL), Alinity Anti-HBc II Reagent Kit from Abbott (based on a cutoff of 1.00 signal-to-cutoff ratio), Alinity HBsAg Reagent Kit from Abbott (LOD of 0.02 IU/mL) were used to determine these markers (Abbott documentation). Only patients who tested positive for anti-HCV antibodies were tested for HCV RNA.
Anti-HCV-positive patients at the first level of screening (positivity for anti-HCV antibodies) were linked to care at the Hepatology Service of the Gastroenterology Division, after additional HCV viremia (HCV RNA) measurement (cobas® HCV-Roche Diagnostics). This test has a minimum limit of quantification (LLOQ) of 15 IU/mL for a sample volume of 500 µL, as per Roche documentation.
Antibody positivity alone, in the absence of HCV-RNA in the serum, indicates a spontaneously resolved infection (in patients who have not already undergone antiviral treatment). Subjects who tested positive for HCV-RNA had the opportunity to undertake a therapeutic process [12].
Subjects who tested positive for HCV-RNA were potentially eligible to be treated with DAA according to the 12 AIFA (Agenzia Italiana del Farmaco, Roma, Italy) criteria, defined based on the opinions expressed by the Scientific Technical Commission and in agreement with the Regions, Scientific Societies, and Patient Associations, which allow treatment of every patient for whom therapy is indicated and appropriate [13].
Regarding HBV infection, all patients in cohort 2 underwent screening for HBV infection. The classification of the European Liver Association [14] provides four diagnostic scenarios: (1) Hepatitis B e antigen (HBeAg)-positive chronic infection, (2) HBeAg-positive chronic hepatitis, (3) HBeAg-negative chronic infection, (4) HBeAg-negative chronic hepatitis. Antiviral therapy, achieving long-term suppression of HBV DNA, leads to significant improvements in clinical outcomes. Currently, treatment with nucleoside/nucleotide analogues is highly safe, effective and these are widely available as generic drugs in most countries. Patients with HBsAg-negativity/anti-HBc-positivity may belong to the following categories: (1) chronic HBV patients with HBsAg sero-clearance, (2) resolved HBV infection without a history of chronicity, and (3) occult HBV infection (HBsAg-negative, anti-HBc positive or negative, low-level HBV replication). These subjects necessitate monitoring and/or preventive measures as they carry a risk of reactivation, leading to severe, potentially fatal outcomes in the case of immunosuppressive therapy [14].
Since immunosuppressive drugs are widely used in gastrointestinal diseases, such as chronic inflammatory bowel disease, sclerosing cholangitis, autoimmune hepatitis and pancreatitis, and liver transplantation, the HBV screening was performed in the gastroenterological cohort (Cohort 2).

2.3. Statistical Analysis

All results are expressed as mean ± standard deviation. Aspartate aminotransferase and alanine aminotransferase data were summarised by the median and interquartile range (IQR), as these variables were non-normally distributed. Frequency (%) and number (N for the total sample, n for a subgroup sample) were used to describe the sociodemographic characteristics of HCV patients and their screening results.
Statistical analysis and graphs were obtained using Excel statistical software.

3. Results

3.1. Study Population

A total of 774 patients with an average age of 79.7 years (F = 362) underwent anti-HCV screening. Figure 1 shows the roadmap for HCV screening.

3.2. First Period of Screening

A total of 567 patients without a history of HCV underwent screening (M = 307; F = 264, average age 82 years) during the study period between October 2021 and July 2022.

3.3. Second Period of Screening

A total of 207 patients, including 169 residents of Siena, participated in the study between May 2024 and October 2024. Their characteristics are detailed in Table 1.
In summary, 47.3% of the patients were female, with an average age of 77.4 years. Medical history reveals a high prevalence of comorbidities, affecting 88.4% of the patients. The most common comorbidities included cardiovascular diseases (68.1%), cancer (35.3%), liver and hepatobiliary diseases (28%), and diabetes (22.2%). Additionally, 15.5% of the patients were receiving immunomodulating drugs.

3.4. Opportunistic Anti-HCV Screening

Across all cohorts, 16 of 774 (2%) patients were anti-HCV-positive.

3.4.1. Cohort 0

In this cohort, newly diagnosed patients with positive anti-HCV antibody tests were 8 out of 567 (1.4%). Transaminase levels were within the normal range.

3.4.2. Cohort 1

At the Internal and Complex Medicine Unit, the subjects enrolled in the study were 63 (M = 33, F = 30, age between 58 and 92 years, mean ± SD =78.5 ± 8.9), of whom 60 were residents in Siena, 1 was a resident in Naples and another 1 in Grosseto; 1 subject had missing residence.
Out of 63 subjects subjected to anti-HCV screening, 62 tested negative for anti-HCV screening, and only one patient tested positive (Table 2).
Furthermore, five patients had a previous history of chronic liver disease, of whom only one patient suffering from HBV-related chronic liver disease also presented transaminase alterations. Overall, the patients had transaminase levels within normal limits (Table 1).

3.4.3. Cohort 2

At the Gastroenterology and Operational Endoscopy Unit, the subjects enrolled in the study were 96 (M = 56, F = 40, age = 75.3 ± 10.3), of whom 10 were of foreign origin (Table 1).
Of the 96 subjects screened for HCV, 94 tested negative, and 2 patients (2%) tested positive (Table 2). One of these patients had already been screened during a previous admission to the Internal Medicine and Geriatrics Unit and was then only tested for viremia.
Furthermore, five patients had a history of chronic liver disease, and four of these patients had liver cirrhosis. During hospitalisation, a diagnosis of cirrhosis was made in two other subjects. Transaminase levels are shown in Table 1.
The prevalent diagnoses in these patients were cardiovascular, liver and hepatobiliary diseases (Table 1).
In this subpopulation of patients (Table 2), screening was also carried out for hepatitis B markers (HBsAg, anti-HBs, anti-HBc). Four patients showed anti-HBc positivity, HBsAg negativity, anti-HBs positivity; four patients had anti-HBc isolate positivity; one patient had HBV infection (HBsAg positivity). The HBsAg-positive patient was a 60-year-old man living in Tuscany and originally from Macedonia, with transaminases within normal limits (AST = 12 IU, ALT = 16 IU), quantitative HBsAg test = 137.90, anti-HBc antibody positive, HBeAg negative, and anti-hepatitis delta antibody negative.

3.4.4. Cohort 3

At the Internal Medicine and Geriatrics Unit, 48 subjects were enrolled in the study (M = 20, F = 28, age between 57 and 105 years, mean ± SD = 80.4 ± 12.0), of whom 43 subjects were residents in Siena and its province, and 3 were of foreign origin (Table 1). None of these patients had a history of chronic liver disease.
Of the 48 subjects who underwent anti-HCV screening, a total of 44 subjects tested negative for anti-HCV screening, and 4 patients tested positive (Table 2).

3.5. Molecular Diagnosis and Linkage to Care

Positive patients for anti-HCV antibodies underwent venous blood sampling to detect HCV RNA. They were linked to care in the Gastroenterology Division.
Overall, we observed a chronic HCV infection prevalence of 0.8% (6/774) (HCV RNA+). In particular, four patients in the first period of screening tested positive (0.7%), while two patients tested positive (Table 2) in the second round (0.9%).
The eight patients with HBsAg-negative (probably resolved HBV infection) received information on their status with a recommendation for monitoring.
The patient with HBsAg positivity was an inactive carrier (HBV DNA negative). The patient was tested for anti-hepatitis delta antibodies, and the results were negative.
Cohort 0: Of eight anti-HCV positive patients, HCV infection was confirmed in four patients (HCV RNA positive).
Cohort 1: In the patient who tested positive for anti-HCV, HCV infection was not confirmed due to a negative PCR result (HCV RNA negative).
Cohort 2. The anti-HCV positive patient transferred from the Internal Medicine and Complex Medicine Unit to the Gastroenterology and Operational Endoscopy Unit, following a positive HCV RNA test, received a prescription for DAA therapy; one patient tested positive for HCV RNA but had end-stage pancreatic cancer disease and, for this reason, he has not received treatment; the third patient tested negative for HCV RNA (Table 2).
Cohort 3. Of four patients who tested positive for anti-HCV antibodies, HCV infection was confirmed in only one patient by PCR positivity (HCV RNA positive), who was transferred to the Gastroenterology and Operational Endoscopy Unit.

4. Discussion

The findings of this study showed an active HCV infection prevalence of 0.8% in hospitalised patients born before 1969. In addition, the results highlighted a low prevalence of active HBV infection. Still, a prevalence of 8.3% at risk for occult HBV infection in a study subgroup of the population residing in South-Eastern Tuscany confirms that an opportunistic screening can identify the unrecognized people affected by the hepatitis virus infection. In the second round of screening, the increase in transaminase levels (30.4%) can be linked to the combined presence of liver and hepatobiliary diseases (28.0%) and the administration of immunomodulatory drugs (15.5%).
The results of our study show an anti-HCV prevalence of 2% in residents of South-Eastern Tuscany (Central Italy) with an average age of about 79 years. This prevalence was similar to that found by Stasi et al. [15] in a previous study conducted in Tuscany, where they analyzed the serological database of a hospital in Prato. This study involved 22,404 subjects (12% of Prato’s population) and showed a 2.2% anti-HCV prevalence increasing with age (0.7% among patients aged 0–14 years, 0.5% among those 15–30 years, 1.5% among those 31–45 years, 2.7% among those 46–60 years and 5.4% among those over 61 years). Instead, the prevalence found in our study was higher than that found by Andriulli et al. [9] in the general population residing in Central Italy born between 1945 and 1954 (anti-HCV positivity = 1.1%). However, considering the older age groups, the results of Andriulli et al. [9] show a peak of 7% in those born between 1935 and 1944. In this study, the overall population exhibited an HCV-RNA prevalence of 1.7%, whereas the prevalence found in our research was 0.8%. However, the study by Andriulli et al. [7] also included subjects who were aware of their condition and was conducted in metropolitan cities. In our study, we included hospitalized patients from the University Hospital of Siena, located in a province (Siena) with low population density, and we excluded participants who had a history of HCV. Therefore, the comparison between this population cohort and the hospitalized one may also present differences in terms of demographic characteristics and lifestyle factors.
The in-hospital setting appears suitable and adequate for implementing an opportunistic screening program to identify HCV infection in the adult population not covered by the free Italian HCV screening. Our results show an overall HCV RNA prevalence of 0.8%, with comparable prevalence in those born before 1969 during the October 2021–July 2022 and May 2024–October 2024 periods, suggesting that we are still far from eliminating HCV. Among the most recent prevalence estimates, the study by Kondili et al. [8] shows an Italian prevalence of 0.66% of subjects with active infection and, specifically for Central Italy, this is 0.88%. Recently, Marcellusi et al. [16] evaluated the cost consequences of three different screening strategies for the active HCV infection in the 1948–1968 birth cohort to achieve the HCV elimination goal. Considering an estimated prevalence of 0.69% for this cohort, Marcellusi et al. [16] highlighted that, by implementing a rapid screening scenario (with a rapid screening coverage rate, which remains high and constant from the first year of implementation), the reductions in clinical outcomes and deaths were higher than the scenario without screening and incremental screening (four years of simulated anti-HCV screening, with increasing coverage of the population screened for each period). A total of 5696 fewer deaths, 3549 fewer HCCs, and 3005 fewer liver failures were estimated compared to the incremental scenario. The overall costs of fast-screening, including the costs of DAAs and the management of liver disease of infected patients for 10 years, are estimated at EUR 43,107,543 more than not investing in screening and EUR 62,289,549 less than the total costs estimated with the incremental scenario.
Therefore, expanding the population cohort screened to people over the age of 55 could facilitate the achievement of the objectives set by the WHO [17]. Furthermore, the eradication objective can be achieved by considering all transmission routes of viral hepatitis and identifying those at the greatest risk of infection.
As is known, the prevalence of chronic viral hepatitis is high in migrants compared to the general population since they have greater exposure to environmental risk factors, plus a higher possibility of encountering barriers (such as linguistic, cultural) in the diagnostic–therapeutic path.
Screening strategies in higher-risk populations are essential for achieving the WHO objective of eradicating HCV and HBV by 2030. According to recent ISTAT data, Siena has a percentage of foreigners in total population equal to 11% [18]. Most studies conducted in disadvantaged populations on national and regional territories [19,20,21,22,23] are in agreement with international studies [24,25,26] and highlight a higher prevalence of HCV and HBV, compared to those recorded in the general population [9,27,28].
In our study, 25% of patients with resolved HBV infection were of foreign origin.
Italy is an HBV low-endemic country (<2%) [29]. A systematic review and meta-analysis estimated that the prevalence of occult HBV prevalence in low-endemicity countries in blood donors was 0.06%, in low-risk groups other than blood donors 2.6%, and in high-risk groups 5.5%. Boccalini et al. [30] evaluated the seroprevalence of three HBV markers (anti-HBs, anti-HBc, and HBsAg) in 430 serum samples from adults aged 18 to 99 years residing in the Province of Florence (Tuscany), finding an anti-HBc seroprevalence of 11%, higher in foreign subjects compared to Italians, which dropped to 2.6% when evaluating pairing samples with an anti-HBc positivity and anti-HBs negativity. We found 8.3% of people with resolved HBV infection and 4.2% of isolated anti-HBc positivity. Both patients with HBV-related chronic liver disease and those with resolved HBV infections are at risk of reactivation, with severe and potentially fatal outcomes in patients receiving immunosuppressive drugs [14,31].
The reactivation risk for both HBsAg-positive and resolved HBV infection is due to persistent covalently closed circular DNA (cccDNA) and can be effectively prevented with antiviral agents [14]. The loss of HBsAg does not correspond to virus clearance since cccDNA remains competent for replication in hepatocytes [32]. Bae et al. [33] studied 114 patients (76 with resolved HBV infection and 38 HBsAg-positive) with frozen specimens of the background liver, demonstrating that anti-HBc titers (≥11.0 sample/cut-off) were positively correlated with intrahepatic cccDNA levels, even in patients with resolved HBV infections.
Fernandez-Garcia et al. [32] conducted a retrospective single-center study to evaluate the risk factors for HBV reactivation in 38 lung transplant recipients who were anti-HBc positive and HBsAg negative. HBV reactivation in anti-HBc positive lung transplant patients was demonstrated in 8% of subjects, despite the presence of anti-HB antibodies, occurring late after transplant, with a 5% rate of mortality. In the gastroenterology cohort in our study, 14.6% of patients were undergoing therapy with immunomodulatory drugs.

5. Conclusions

Our study indicates a similar prevalence of HCV in individuals born before 1969 from October 2021 to July 2022 and from May 2024 to October 2024, suggesting that we are still far from eliminating HCV. The study also highlighted a prevalence of 8.3% of people at risk for occult HBV infection in a subgroup of patients residing in South-Eastern Tuscany.
Given that opportunistic screening has led to the early diagnosis of viral hepatitis infections in people previously unaware of the disease, we suggest that these screening channels can identify unrecognized people affected by the hepatitis virus infection.

Author Contributions

C.S. investigation, data curation, formal analysis, methodology, visualization, writing—review and editing; T.M., F.N. and S.P. performed investigation and data collection; G.G. performed data collection; S.R., R.M. and L.G. contributed to the study investigation; R.A. and P.E.L. contributed to the investigation, methodology, supervision, review; S.B. contributed to conceptualization, project administration, investigation, methodology, supervision, review. All authors: manuscript reviewing. All authors have read and agreed to the published version of the manuscript.

Funding

This study was not supported by any sponsor or funder.

Institutional Review Board Statement

The study was approved by the local Ethics Committee (Prot. N. 20554).

Informed Consent Statement

Informed consent was obtained from all subjects involved in the study.

Data Availability Statement

The original contributions presented in the study are included in the article, further inquiries can be directed to the corresponding author.

Acknowledgments

Thanks to the Le Scotte HCV screening group. (Pier Leopoldo Capecchi, Ivano Biviano, Alessia Santini, Sinan Sadalla, Alessandra Lucenti Fei, Stefano Giannitti, Marta Baldini, Gaia Cairoli, Ilaria Di Rella, Lorenzo Bini, Mauro Mitilini) for their invaluable support for the investigation.

Conflicts of Interest

Prof. Brillanti reports grants and personal fees from Gilead Sciences, outside the submitted work. The authors declare no conflicts of interest.

References

  1. World Health Organization. Global Health Sector Strategy on Viral Hepatitis 2016–2021. Available online: http://apps.who.int/iris/bitstream/10665/246177/1/WHO-HIV-2016.06-eng.pdf (accessed on 10 June 2016).
  2. Kim, H.N.; Corcorran, M.A. Treatment of HCV in Persons with HIV Coinfection. Available online: https://www.hepatitisc.uw.edu/go/key-populations-situations/treatment-hiv-coinfection/core-concept/all (accessed on 24 January 2024).
  3. Polaris Observatory. The Authoritative Resource for Epidemiological Data, Modeling Tools, Training, and Decision Analytics to Support Global Elimination of Hepatitis B and C by 2030. Available online: http://www.hepbunited.org/assets/Webinar-Slides/8b54a78215/POLARIS-Brief-181217.pdf (accessed on 12 June 2024).
  4. World Health Organization. Hepatitis C. Available online: https://www.who.int/news-room/fact-sheets/detail/hepatitis-c (accessed on 9 April 2024).
  5. Thomas, A.M.; Litwin, A.H.; Tsui, J.I.; Sprecht-Walsh, S.; Blalock, K.L.; Tashima, K.T.; Lum, P.J.; Feinberg, J.; Page, K.; Mehta, S.H.; et al. Retreatment of Hepatitis C Virus Among People Who Inject Drugs. Clin. Infect. Dis. 2025, ciaf082. [Google Scholar] [CrossRef]
  6. Falade-Nwulia, O.; Sulkowski, M.S.; Merkow, A.; Latkin, C.; Mehta, S.H. Understanding and addressing hepatitis C reinfection in the oral direct-acting antiviral era. J. Viral Hepat. 2018, 25, 220–227. [Google Scholar] [CrossRef]
  7. Stasi, C.; Silvestri, C.; Voller, F. Update on Hepatitis C Epidemiology: Unaware and Untreated Infected Population Could Be the Key to Elimination. SN Compr. Clin. Med. 2020, 2, 2808–2815. [Google Scholar] [CrossRef] [PubMed]
  8. Kondili, L.A.; Andreoni, M.; Aghemo, A.; Mastroianni, C.M.; Merolla, R.; Gallinaro, V.; Craxì, A. Prevalence of hepatitis C virus estimates of undiagnosed individuals in different Italian regions: A mathematical modelling approach by route of transmission and fibrosis progression with results up to January 2021. New Microbiol. 2022, 45, 249–259. [Google Scholar] [PubMed]
  9. Andriulli, A.; Stroffolini, T.; Mariano, A.; Valvano, M.R.; Grattagliano, I.; Ippolito, A.M.; Grossi, A.; Brancaccio, G.; Coco, C.; Russello, M.; et al. Declining prevalence and increasing awareness of HCV infection in Italy: A population-based survey in five metropolitan areas. Eur. J. Intern. Med. 2018, 53, 79–84. [Google Scholar] [CrossRef]
  10. Ministero della Salute. DECRETO 14 Maggio 2021. Esecuzione dello Screening Nazionale per L’eliminazione del Virus dell’HCV. (21A04075) (GU Serie Generale n.162 del 08-07-2021). Available online: https://www.gazzettaufficiale.it/eli/id/2021/07/08/21A04075/sg (accessed on 8 July 2021).
  11. REGIONE TOSCANA. Avvio di un Programma di Screening Gratuito per Prevenire, Eliminare ed Eradicare il Virus Dell’epatite C, in Attuazione Dell’art. 25-Sexies del D.L.n. 162/2019. Available online: http://www301.regione.toscana.it/bancadati/atti/Contenuto.xml?id=5355950&nomeFile=Delibera_n.1538_del_27-12-2022 (accessed on 31 December 2022).
  12. European Association for the Study of the Liver. EASL Recommendations on Treatment of Hepatitis C 2018. J. Hepatol. 2018, 69, 461–511. [Google Scholar] [CrossRef]
  13. Agenzia Italiana del Farmaco. Registri AIFA per il Monitoraggio dei Farmaci Anti-HCV. Last Update March 31. 2025. Available online: https://www.aifa.gov.it/aggiornamento-epatite-c (accessed on 1 April 2025).
  14. European Association for the Study of the Liver. EASL Clinical Practice Guidelines on the management of hepatitis B virus infection. J. Hepatol. 2025; In Press. [CrossRef]
  15. Stasi, C.; Silvestri, C.; Bravi, S.; Aquilini, D.; Casprini, P.; Epifani, C.; Voller, F.; Cipriani, F. Hepatitis B and C epidemiology in an urban cohort in Tuscany (Italy). Clin. Res. Hepatol. Gastroenterol. 2015, 39, e13–e15. [Google Scholar] [CrossRef] [PubMed]
  16. Marcellusi, A.; Mennini, F.S.; Andreoni, M.; Kondili, L.A.; PITER Collaboration Study Group. Screening strategy to advance HCV elimination in Italy: A cost-consequence analysis. Eur. J. Health Econ. 2024, 25, 1261–1273. [Google Scholar] [CrossRef]
  17. Stasi, C.; Milli, C.; Voller, F.; Silvestri, C. The Epidemiology of Chronic Hepatitis C: Where We Are Now. Livers 2024, 4, 172–181. [Google Scholar] [CrossRef]
  18. Istat. Il Censimento permanente della popolazione in Toscana. Available online: https://www.istat.it/wp-content/uploads/2024/05/Toscana_Focus2022.pdf (accessed on 9 April 2024).
  19. Puglia, M.; Stasi, C.; Da Frè, M.; Voller, F. Prevalence and characteristics of HIV/HBV and HIV/HCV coinfections in Tuscany. Braz. J. Infect. Dis. 2016, 20, 330–334. [Google Scholar] [CrossRef]
  20. Stasi, C.; Silvestri, C.; Fanti, E.; Di Fiandra, T.; Voller, F. Prevalence and features of chronic viral hepatitis and HIV coinfection in Italian prisons. Eur. J. Intern. Med. 2016, 34, e21–e22. [Google Scholar] [CrossRef] [PubMed]
  21. Stasi, C.; Monnini, M.; Cellesi, V.; Salvadori, M.; Marri, D.; Ameglio, M.; Gabbuti, A.; Di Fiandra, T.; Voller, F.; Silvestri, C. Screening for hepatitis B virus and accelerated vaccination schedule in prison: A pilot multicenter study. Vaccine 2019, 37, 1412–1417. [Google Scholar] [CrossRef] [PubMed]
  22. Silvestri, C.; Stasi, C.; Lazzeretti, M.; Voller, F. Substance Abuse Disorder and Viral Infections (Hepatitis, HIV): A Multicenter Study in Tuscan Prisons. J. Correct. Health Care 2021, 27, 161–166. [Google Scholar] [CrossRef] [PubMed]
  23. Monti, M.; Caruso, T.; Castellaccio, A.; De Giorgi, I.; Cavallini, G.; Manca, M.L.; Lorini, S.; Marri, S.; Petraccia, L.; Madia, F.; et al. HBV and HCV testing outcomes among marginalized communities in Italy, 2019-2024: A prospective study. The Lancet regional health. Europe 2024, 49, 101172. [Google Scholar] [CrossRef]
  24. Mourad, A.; McGeer, R.; Gray, E.; Bibby-Jones, A.M.; Gage, H.; Salvaggio, L.; Charles, V.; Sanderson, N.; O’Sullivan, M.; Bird, T.; et al. A novel multisite model to facilitate hepatitis C virus elimination in people experiencing homelessness. JHEP Rep. 2024, 6, 101183. [Google Scholar] [CrossRef]
  25. Degenhardt, L.; Peacock, A.; Colledge, S.; Leung, J.; Grebely, J.; Vickerman, P.; Stone, J.; Cunningham, E.B.; Trickey, A.; Dumchev, K.; et al. Global prevalence of injecting drug use and sociodemographic characteristics and prevalence of HIV, HBV, and HCV in people who inject drugs: A multistage systematic review. The Lancet. Glob. Health 2017, 5, e1192–e1207. [Google Scholar] [CrossRef]
  26. Busschots, D.; Kremer, C.; Bielen, R.; Koc, Ö.M.; Heyens, L.; Nevens, F.; Hens, N.; Robaeys, G. Hepatitis C prevalence in incarcerated settings between 2013-2021: A systematic review and meta-analysis. BMC Public Health 2022, 22, 2159. [Google Scholar] [CrossRef]
  27. Gower, E.; Estes, C.; Blach, S.; Razavi-Shearer, K.; Razavi, H. Global epidemiology and genotype distribution of the hepatitis C virus infection. J Hepatol. 2014, 61 (Suppl. 1), S45–S57. [Google Scholar] [CrossRef]
  28. Silvestri, C.; Bartolacci, S.; Pepe, P.; Monnini, M.; Voller, F.; Cipriani, F.; Stasi, C. Attempt to calculate the prevalence and features of chronic hepatitis C infection in Tuscany using administrative data. World J. Gastroenterol. 2016, 22, 9829–9835. [Google Scholar] [CrossRef]
  29. Im, Y.R.; Jagdish, R.; Leith, D.; Kim, J.U.; Yoshida, K.; Majid, A.; Ge, Y.; Ndow, G.; Shimakawa, Y.; Lemoine, M. Prevalence of occult hepatitis B virus infection in adults: A systematic review and meta-analysis. Lancet Gastroenterol. Hepatol. 2022, 7, 932–942. [Google Scholar] [CrossRef]
  30. Boccalini, S.; Zanella, B.; Del Riccio, M.; Bonito, B.; Biamonte, M.A.; Bruschi, M.; Ionita, G.; Paolini, D.; Innocenti, M.; Baggiani, L.; et al. Impact of the Hepatitis B Immunization Strategy Adopted in Italy from 1991: The Results of a Seroprevalence Study on the Adult Population of Florence, Italy. Pathogens 2025, 14, 362. [Google Scholar] [CrossRef]
  31. Stasi, C.; Tiengo, G.; Sadalla, S.; Zignego, A.L. Treatment or Prophylaxis against Hepatitis B Virus Infection in Patients with Rheumatic Disease Undergoing Immunosuppressive Therapy: An Update. J. Clin. Med. 2021, 10, 2564. [Google Scholar] [CrossRef] [PubMed]
  32. Fernandez-Garcia, O.A.; Zelyas, N.; Meier-Stephenson, V.; Halloran, K.; Doucette, K. Hepatitis B virus reactivation in hepatitis B core antibody positive lung transplant recipients. JHLT Open 2023, 3, 100018. [Google Scholar] [CrossRef] [PubMed]
  33. Bae, S.K.; Arita, J.; Akamatsu, N.; Ichida, A.; Nishioka, Y.; Miyata, A.; Kawahara, T.; Inagaki, Y.; Kawaguchi, Y.; Kaneko, J.; et al. Prediction of intrahepatic covalently closed circular DNA levels in patients with resolved hepatitis B virus infection: Impact of serum antibody to hepatitis B core antigen titers. Hepatol. Res. 2025, 55, 471–478. [Google Scholar] [CrossRef] [PubMed]
Livers 05 00030 g001
Figure 1. Algorithm for screening HCV patients.
Figure 1. Algorithm for screening HCV patients.
Livers 05 00030 g001
Table 1. Demographic and clinical features of patients in the study population of the second screening period and the three sub-cohorts.
Table 1. Demographic and clinical features of patients in the study population of the second screening period and the three sub-cohorts.
Overall
Population (Second Screening Period)		Cohort 1Cohort 2Cohort 3
Patients, n207639648
  Demography
    Age, y77.4 ± 8.578.5 ± 8.975.3 ± 10.380.4 ± 12.0
    Female, n (%)98 (47.3)30 (47.6)40 (41.7)28 (58.3)
    Residence
               Italy, n (%)202 (97.6)62 (98.4)92 (96.0)48 (100)
                             Tuscany, n (%)191 (92.3)61 (96.8)83 (86.5)47 (97.9)
                             Siena, n (%)169 (81.6)60 (95.3)66 (68.7)43 (89.5)
               Foreign origin, n (%)13 (6.2)-10 (10.42)3 (6.25)
Medical history
Comorbidities, n (%)183 (88.4)60 (95.2)86 (89.5)37 (77.1)
Cardiovascular diseases, n (%)141 (68.1)50 (79.3)65 (67.7)26 (54.2)
Heart failure, n (%)48 (23.2)20 (31.7)7 (7.3)21 (43.8)
Coronary artery disease, n (%)25 (12.1)3 (4.7)10 (10.4)12 (25.0)
Chronic kidney disease, n (%)37 (17.9)14 (22.2)14 (14.6)9 (18.8)
Diabetes, n (%)46 (22.2)10 (15.8)26 (27.1)10 (20.8)
COPD, n (%)31 (15.0)12 (19)11 (11.5)8 (16.6)
Liver and Hepatobiliary diseases, n (%)58 (28.0)2 (3.2)38 (39.5)18 (37.5)
Liver cirrhosis, n (%)24 (11.6)-6 (6.2)18 (37.5)
Hepatobiliary, n (%)28 (13.53)1 (1.6)27 (28.1)-
Cancer, n (%)73 (35.3)21 (33.3)33 (34.4)19 (39.6)
Hepatobiliary, n (%)--7 (7.3)-
HCC, n (%)2 (1.0)1 (1.5)1 (1.0)-
Immune-mediated diseases, n (%)19 (9.2)5 (7.9)12 (12.5)2 (4.1)
IBD, n (%)6 (2.9)-6 (6.5)-
Rheumatoid arthritis, n (%)3 (1.4)1 (1.6)2 (2)-
Ankylosing spondylitis, n (%)2 (0.9) 2 (2)
Vasculitis, n (%)2(0.9)1 (1.6)-1 (2)
Systemic lupus erythematosus, n (%)1 (0.5)1 (1.6)--
Common variable immunodeficiency, n (%) --1 (2)
Therapy
Immuno-modulating drugs, n (%)32 (15.5)10 (15.8)14 (14.6)8 (16.6)
Glucocorticoids, n (%)27 (13.0)8 (12.6)13 (13.5)6 (12.5)
Mean daily dose *, mg24.519.217.037.3
Biologic drugs, n (%)6 (2.9)2 (3.2)1 (1.0)3 (6.3)
Other immunosuppressants, n (%)2 (1.0)-2 (2)-
Laboratory data
Transaminase elevation, n (%)63 (30.4)10 (15.9)46 (48.0)7 (14.6)
AST levels, IU/L (median, IQR)21 (38.5–15)20 (29–14)26 (65−17)19 (31.7–14)
ALT levels, IU/L (median, IQR)18 (41–11)16 (24–11)29 (86.5–13)17 (27–11)
AST: aspartate aminotransferase. ALT: alanine-aminotransferase; COPD: chronic obstructive pulmonary disease. * prednisone equivalent dose. Values are expressed as frequence (percentage) or mean ± standard deviation or median and interquartile range (IQR). AST normal range = 0–40 UI/L; ALT normal range = 0–40 UI/L. AST and ALT levels refer to all patients.
Table 2. Demographic and laboratory parameters of anti-HCV and HBV-positive patients in the study population of the second screening period.
Table 2. Demographic and laboratory parameters of anti-HCV and HBV-positive patients in the study population of the second screening period.
Overall
Population		Cohort 1Cohort 2Cohort 3
HCV infection, n (%)8 (3.9)1(1.6)3 (3.1)4 (8.3)
HCV antibody-positive, n (%)8 (3.9)1(1.6)3 (3.1)4 (8.3)
        Age, y73.3 ± 10.78865.6 ± 9.075.3 ± 10.4
        Female, n (%)5 (2.4)-1 (1)4 (8.3)
         Comorbidities, n (%)8 (3.9)1 (1.6)3 (3.1)4 (8.3)
        Transaminasis elevation, n (%)2 (0.9)02 (2.1)0
                     AST levels, IU/L22 (75.7–15.7)570 (93–16)22 (23–15)
                     ALT levels, IU/L16 (41–10)1041 (71–16)14 (36–7)
HCV RNA-positive, n (%)2 (0.9)02 (2.1)0
        Age, y76-76-
        Female, n (%)1 (0.5)-1 (1)-
        Comorbidities, n (%)2 (0.9)-2 (2.1)-
        Therapy, n (%)1 (0.5) DAA-1 (1) DAA-
        Transaminasis elevation, n (%)0-0-
                    AST levels, IU/L22 and 16-22 and 16-
                    ALT levels, IU/L36 and 16-36 and 16-
HBV markers, n (%)9 (9.4)-9 (9.4)-
         Age, y80.0 ± 4.9-80.0 ± 4.9-
         Female, n (%)3 (3.1)-3 (3.1)-
         Comorbidities, n (%)9 (9.4)-9 (9.4)-
         Therapy----
         Transaminase elevation, n (%)3 (3.1)-3 (3.1)-
                      AST levels, IU/L(median, IQR)24 (63.5–18.5)-24 (63.5–18.5)-
                      ALT levels, IU/L(median, IQR)25 (56–13.5)-25 (56–13.5)-
         HBsAg+1 (1)-1 (1)-
         Anti-HBc+4 (4.2)-4 (4.2)-
         Anti-HBc+ and anti-HBs+4 (4.2)-4 (4.2)-
AST, aspartate aminotransferase. ALT, alanine aminotransferase; DAA, direct-acting antivirals. Values are expressed as frequency (percentage) or mean ± standard deviation or median and interquartile range (IQR).
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Stasi, C.; Marzotti, T.; Nassi, F.; Giugliano, G.; Pacini, S.; Rentini, S.; Accioli, R.; Macchiarelli, R.; Gennari, L.; Lazzerini, P.E.; et al. Hepatitis C Virus Opportunistic Screening in South-Eastern Tuscany Residents Admitted to the University Hospital in Siena. Livers 2025, 5, 30. https://doi.org/10.3390/livers5030030

AMA Style

Stasi C, Marzotti T, Nassi F, Giugliano G, Pacini S, Rentini S, Accioli R, Macchiarelli R, Gennari L, Lazzerini PE, et al. Hepatitis C Virus Opportunistic Screening in South-Eastern Tuscany Residents Admitted to the University Hospital in Siena. Livers. 2025; 5(3):30. https://doi.org/10.3390/livers5030030

Chicago/Turabian Style

Stasi, Cristina, Tommaso Marzotti, Filippo Nassi, Giovanna Giugliano, Sabrina Pacini, Silvia Rentini, Riccardo Accioli, Raffaele Macchiarelli, Luigi Gennari, Pietro Enea Lazzerini, and et al. 2025. "Hepatitis C Virus Opportunistic Screening in South-Eastern Tuscany Residents Admitted to the University Hospital in Siena" Livers 5, no. 3: 30. https://doi.org/10.3390/livers5030030

APA Style

Stasi, C., Marzotti, T., Nassi, F., Giugliano, G., Pacini, S., Rentini, S., Accioli, R., Macchiarelli, R., Gennari, L., Lazzerini, P. E., & Brillanti, S., on behalf of Le Scotte HCV Screening Group. (2025). Hepatitis C Virus Opportunistic Screening in South-Eastern Tuscany Residents Admitted to the University Hospital in Siena. Livers, 5(3), 30. https://doi.org/10.3390/livers5030030

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