Cdc Recommendations For Hcv Screening
On April 10, 2020, the Centers for Disease Control and Prevention issued new recommendations for hepatitis C screening among adults in the United States . This new guidance augments prior CDC guidance on HCV screening with two new major recommendations: all adults aged 18 years and older should have HCV screening at least once in their lifetime, except in settings where the prevalence of HCV infection is less than 0.1%, and HCV screening should be performed for all pregnant persons during each pregnancy, except in settings where the prevalence of HCV infection is less than 0.1%. The CDC continues to recommend screening persons for HCV regardless of age if risk factors for acquiring HCV are present, with repeat periodic screening in persons who have ongoing risk for acquiring HCV. These new CDC HCV screening recommendations expand prior guidance that recommended routine HCV screening for all persons born between 1945-1965.
Virus Description And Transmission
HCV is a small, single-stranded, enveloped RNA virus in the flavivirus family with a high degree of genetic heterogeneity. Seven distinct HCV genotypes have been identified. Genotype 1 is the most prevalent genotype in the United States and worldwide, accounting for approximately 75% and 46% of cases, respectively . Geographic differences in global genotype distribution are important because some treatment options are genotype specific . High rates of mutation in the HCV RNA genome are believed to play a role in the pathogens ability to evade the immune system . Prior infection with HCV does not protect against subsequent infection with the same or different genotypes.
HCV is primarily transmitted through direct percutaneous exposure to blood. Mucous membrane exposures to blood also can result in transmission, although this route is less efficient. HCV can be detected in saliva, semen, breast milk, and other body fluids, although these body fluids are not believed to be efficient vehicles of transmission .
Factors Considered When Determining The Recommendations
Four factors must be considered when determining the relevance and strength of a GRADE-based recommendation: quality of evidence, balance between benefits and harms, values and preferences, and resource implications. During the consultation, the Work Group considered each of these factors in light of the evidence presented.
Determining the Quality of the Evidence Across Outcomes Critical for Decision Making
The systematic reviews revealed a lack of evidence directly comparing the effectiveness of birth-year based testing to risk-based testing. Thus, the Work Group considered available evidence from studies examining 1) nationally representative observational data on HCV prevalence among varying birth cohorts, 2) clinical trial data on the effect of HCV treatment on achieving SVR, 3) observational data on the association of SVR with HCC and all-cause mortality, and 4) data from a meta-analysis of randomized controlled trials on the effectiveness of brief alcohol interventions in reducing alcohol use. Evidence from these studies was reviewed comprehensively to infer that birth-year based testing, in combination with alcohol reduction interventions, will lead to enhanced identification and treatment of the infected population and result in reduced morbidity and mortality.
Benefits versus Harms
Values and Preferences
Resource Implications
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Why Are Baby Boomers At A Higher Risk
While injection drug use is a risk factor, the biggest reason baby boomers are more likely to have hepatitis C is probably due to unsafe medical procedures at the time. In the past, there was no protocol or screening method to check if a blood supply was virus-free. A 2016 study by points to unsafe medical procedures of the time rather than drug use as the primary reason behind hepatitis C transmission in baby boomers. Researchers behind the study found that:
- the disease spread before 1965
- the highest infection rates happened during the 1940s and 1960s
- the population that got infected stabilized around 1960
These findings refute the stigma of drug use around the disease. Most baby boomers were far too young to knowingly engage in risky behavior.
Intravenous drug abuse is still considered a significant risk factor for this disease . But according to Hep C Mag, even people who didnt contract hep C by injecting drugs still face this stigma. A person can also carry the virus for a long time before it causes symptoms. This makes it even more difficult to determine when or how the infection occurred.
The increased risk baby boomers are subject to is also a matter of time and place: They came of age before hepatitis C was identified and routinely tested for.
Over 250000 Canadians Believed To Be Infected But Many Unaware They Have Blood
Canadians born between 1945 and 1975 should be tested for the potentially liver-destroying virus hepatitis C, a new set of guidelines recommends.
More than 250,000 Canadians are believed to be infected with hepatitis C, but an estimated 40 to 70 per cent are unaware they harbour the blood-borne virus because it can take decades before symptoms become evident. Chronic infection can lead to cirrhosis of the liver or liver cancer.
The Canadian Association for the Study of the Liver, a national group of health-care providers and researchers, published its guidelines on testing and treating hepatitis C in Monday’s edition of the CMAJ.
A key recommendation is that people be tested based on their age not only possible risk factors, said Dr. Jordan Feld, a liver specialist at Toronto’s University Health Network and a co-author of the guidelines.
“And the reason we’ve done this is it just happens that somewhere between two-thirds and three-quarters of people with hepatitis C were born between 1945 and 1975 in Canada,” he said.
“So just the way someone gets a blood pressure check or a cholesterol check or a colonoscopy based on their age, we would recommend that they get a hepatitis C test if they’re born between those years.
“And if we do that, we hopefully diagnose the vast majority of people living with hepatitis C.”
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Why Screen Baby Boomers For Hepatitis C
Why are we recommending screening of adults in the baby boomer generation? To understand this, its worth reviewing how we got here.
In 1998, the Centers for Disease Control and Prevention established HCV testing guidelines based on the presence of risk factors. These included receipt of blood transfusions prior to 1992, when blood donations began to be screened for HCV receipt of clotting factors before 1987 hemodialysis and injection drug use. However, not many cases of hepatitis C were diagnosed. This could likely be traced to a combination of doctors not being adequately engaged, and patients in denial of their risky behaviors.
To identify more cases, the CDC jettisoned its old approach and moved to a blanket recommendation to screen all adults born between 1945 and 1965, the baby boomers. The rationale for this was that more than three out of every 100 baby boomers were infected with HCV. This was at least five times higher than in any other group of adults, and accounted for about 75% of HCV cases.
Moreover, the diagnosis of HCV in this group would identify those with long-duration chronic disease, who were at risk for the most advanced forms of liver disease. So in 2012, the CDC and United States Preventive Services Task Force formally recommended that all baby boomers get a one-time blood test to check for HCV.
Baby Boomers And Hepatitis C: Whats The Connection
- By Raymond Chung, MD, Contributor
Hepatitis C is a viral infection that is spread through contact with infected blood. Hepatitis C infection can be short-term or long-term . Most people with acute hepatitis C eventually develop chronic hepatitis C.
Hepatitis C usually does not cause symptoms, which is why most people with hepatitis C dont know that they are infected. Left untreated, hepatitis C can lead to cirrhosis, liver cancer, and liver failure.
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Consideration Of A New Hcv Testing Strategy
Because of the limited effectiveness of risk-based HCV testing, the rising HCV-associated morbidity and mortality, and advances in HCV care and treatment, CDC has evaluated public health strategies to increase the proportion of infected persons who know their HCV infection status and are linked to care. Several analyses of nationally representative data have found a disproportionately high prevalence of HCV infection among persons who were born during the mid-1940s through the mid-1960s. In an analysis of 19881994 NHANES data, 65% of 2.7 million persons with HCV infection were aged 3049 years , roughly corresponding to this birth cohort. In an analysis of NHANES data during 19992002, a similarly high proportion of persons with HCV antibody had been born during 19451964 . A recent analysis of 19992008 NHANES data found that the prevalence of HCV antibody among persons in the 19451965 birth cohort was 3.25% persons born during these years accounted for more than three fourths of the total anti-HCV prevalence in the United States .
Selection of a Target Birth Cohort
To select a target birth cohort for an expanded testing strategy, CDC considered various birth cohorts with increased HCV prevalence . For each proposed cohort, CDC determined the weighted, unadjusted anti-HCV prevalence and the size of the population.
Prevalence of HCV Infection in the 19451965 Birth Cohort
What Is Hepatitis C
Hepatitis C is an infection that causes liver inflammation. There are five different types of hepatitis, some of which are caused by viruses. In the United States, we mostly see hepatitis A, B and C, with hepatitis C being the most common type. Hepatitis C is transmitted through contact with infected blood.
The virus which usually produces no obvious symptoms for decades remains in the blood of about 75 percent of those exposed. If left undiagnosed and untreated, the hepatitis C virus can cause scarring , cirrhosis, liver cancer and end stage liver disease. Hepatitis C is the leading cause of liver cancer.
“Unfortunately, the liver doesn’t let you know theres a problem until it’s really, really sick,” says Wolf. “But that can be prevented by getting tested, treated and cured for hepatitis C.”
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Other Risks Can Include:
- Sharing personal care items that may have come in contact with another persons blood, such as razors, toothbrushes or nail clippers
- Inoculation practices involving multiple use needles or immunization air guns
- Exposure of broken skin to HCV infected blood
- HIV infected persons
People with current or past risk behaviors should consider HCV testing and consult with a physician. HCV testing is currently not available at most public health clinics in Missouri. For information about HCV testing that is available, call the HCV Program Coordinator at 573-751-6439.
Ask An Expert: Why Should Baby Boomers Get Tested For Hepatitis C
If you were born between 1945 and 1965, now is the time to consider getting tested for the hepatitis C virus. Baby boomers are five times more likely to have the hepatitis C virus, according to the U.S. Centers for Disease Control and Prevention.
Even if you feel fine, its important to get tested. Thats because hepatitis C is a silent diseasemost people with the virus can go years, even decades, before symptoms appear. At that point, life-threatening liver disease, including cirrhosis and liver cancer, has begun.
We asked University of Iowa Health Care hepatologist Alan Gunderson, MD, to provide details.
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Staying Healthy With Hepatitis
Not everyone needs treatment right away, but its important to be monitored regularly by an experienced doctor and discuss treatment options of the best way to keep you healthy.
- Get vaccinated against Hepatitis A and Hepatitis B
- Avoid alcohol and drugs
- Eat a healthy & balanced diet. Include a lot of vegetables and fruits try to stay away from too much salt, sugar and fat.
- Exercise regularly. Walking is one of the best exercises, and it helps to make you feel less tired.
- Check with a health professional before taking any prescription pills, supplements, or over-the-counter medications.
- Do not share razors, nail clippers, needles or other items that come in contact with blood with other people.
Screening And Hcv Testing
The patient population consisted of any patient born between 1945 and 1965 who obtained a routine screening test for hepatitis C in the ED during the time period of June 1, 2016, to December 31, 2016. An opt-out HCV test order was automatically generated in the electronic medical record for birth cohort patients seen in the ED from 11 am7 pm daily as a result of a service grant. This HCV test order was linked to the service grant principal investigator , enabling exclusion of any patients who obtained an HCV test for diagnostic or any other nonscreening purpose. The testing hours were based on when the ED saw the most patients and the availability of grant personnel for questions from patients or staff. Patients received a handout explaining the rationale for screening and that they could refuse testing. The handout also stated that patients would be contacted with results and provided the phone number of the linkage to care coordinator for questions or concerns. Patients could be excluded from screening at the discretion of any ED provider, including emergencies or inability to consent. Elecsys Anti-HCV COBAS Modular e601 was performed on all samples to test for HCV Ab. Patients who tested HCV Ab positive were automatically reflexed to the COBAS AmpliPrep/TaqMan HCV Quantitative Test v2.0 to determine HCV VL.
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Management Of Persons Tested For Hcv Infection
Communicating Test Results to Persons Tested for HCV
Negative Anti-HCV Test Results
Persons with negative anti-HCV test results should be informed of their test results and reassured that they are not infected unless they were recently at risk for infection . Repeat testing should be considered for persons with ongoing risk behaviors.
Positive Anti-HCV and Negative HCV RNA Test Results
Persons who are anti-HCV positive but have an HCV RNA-negative test result should be informed that they do not have HCV infection and do not need follow-up testing.
Positive Anti-HCV and HCV RNA Test Results
Persons who test positive for both HCV antibody and HCV RNA should be informed that they have HCV infection and need further medical evaluation for liver disease, ongoing medical monitoring, and possible treatment. At the time positive test results are communicated to patients, health-care providers should evaluate the patient’s level of alcohol use and provide a brief alcohol intervention if clinically indicated . Persons with HCV infection also should be provided information about 1) HCV infection, 2) risk factors for disease progression, 3) preventive self-care and treatment options, and 4) how to prevent transmission of HCV to others. HCV-infected persons also should be informed about the resources available to them within their communities, including providers of medical evaluation and social support.
Post-Test Counseling Messages
Public Health Testing Criteria
HCV testing of persons in the 19451965 birth cohort is consistent with established general public health screening criteria as evidenced by the following factors: 1) HCV infection is a substantial health problem that affects a large number of persons, causes negative health outcomes, and can be diagnosed before symptoms appear 2) testing for HCV infection is readily available, minimally invasive, and reliable 3) benefits include limiting disease progression and facilitating early access to treatments that can save significant life years and 4) testing is cost effective. Such testing would help identify unrecognized infections, limit transmission, and help HCV-infected persons receive beneficial care and treatment before onset of severe HCV-related disease .
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Screening And Treating Patients
Screening for the hepatitis C virus, or HCV, involves an inexpensive blood test. Most people exposed to the virus are able to clear the infection.
“As the landscape has evolved such that everyone can access therapy we felt much more strongly that then everyone who is at risk should be tested,” said Feld’s co-lead author, Dr. Hemant Shah, a liver specialist and clinical practice director of the Francis Family Liver Clinic at Toronto’s University Health Network.
Joe Camara learned he contracted hepatitis C in 1993 after using intravenous drugs. The Toronto man was sent to the U.S. for treatment.
“I was throwing up. I would turn all yellow. Just sick,” he recalled. Since Camara started receiving direct-acting antiviral medication, he says his energy has returned and he feels great.
Eliminate Viral Hepatitis C By 2030
Bernadette Lettner, a registered nurse at the Regent Park Community Health Centre in Toronto, where Camara is now treated, points out that Canada has signed on to the WHO commitment to eliminate viral hepatitis C by 2030.
“I think that if you commit to doing something like that, then you’re going to have to make sure you’re able to test people who previously wouldn’t know that they’re hep C positive,” she said.
According to Lettner, many of those who are unaware are baby boomers. “The majority of new cases are in people who inject drugs or in prison populations,” she said.
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What Is The Hepatitis C Screening
The hepatitis C screening test is a blood test that checks to see if you have antibodies to the hepatitis C virus in your bloodstream. The antibiodies show youve been exposed to the hepatitis C virus. If your test comes back positive for the antibodies, an additional blood test can confirm whether the virus is still active, or chronic in your body.
Reactive Or Positive Hepatitis C Antibody Test
- A reactive or positive antibody test means that Hepatitis C antibodies were found in the blood and a person has been infected with the Hepatitis C virus at some point in time.
- Once people have been infected, they will always have antibodies in their blood. This is true even if they have cleared the Hepatitis C virus.
- A reactive antibody test does not necessarily mean that you have Hepatitis C. A person will need an additional, follow-up test.
Persons for Whom HCV Testing Is Recommended
- Adults born from 1945 through 1965 should be tested once
- Those who:
- Ever injected drugs, including those who injected once or a few times many years ago
- Have certain medical conditions, including persons:
- who received clotting factor concentrates produced before 1987
- who were ever on long-term hemodialysis
- with persistently abnormal alanine aminotransferase levels
- who have HIV infection
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