Hep C Recommends

CDC Recommends that All Baby Boomers Be Tested Once for Hepatitis C

 

Print This Post Print This Post

The U.S. Centers for Disease Control and Prevention now recommends that all U.S. baby boomers get a one-time test for the hepatitis C virus.  One in 30 baby boomers—those born from 1945 to 1965—is infected with hepatitis C, but as many as 50% may not know it.  

Hepatitis C infection is a contagious liver condition that ranges in severity from a mild illness lasting a few weeks to a chronic, lifelong illness. It results from infection with the hepatitis C virus (HCV) and is spread primarily through blood-to-blood contact.  The most likely source of the infection is the use of injectable drugs, including intermittent or short-term usage that may have occurred years ago.  HCV infection status is determined by a blood test and unlike hepatitis A and B, there is currently no vaccine to prevent infection with HCV.

In those patients infected with HCV, it persists as a chronic infection in approximately 75%-85% of cases.[1] Chronic hepatitis C causes serious liver diseases including liver cancer, which is the fastest-rising cause of cancer-related deaths and the leading cause of liver transplants in the United States.  More than 15,000 Americans die each year from hepatitis C-related illness, such as cirrhosis and liver cancer; deaths have been increasing steadily for over a decade and are projected to grow significantly in coming years.  Of note is the fact that hepatitis C affects four times more Americans than HIV and that more Americans now die from hepatitis C than from HIV.[2]

Baby boomers are five times more likely than other American adults to be infected with HCV and in fact, more than 75% of American adults with hepatitis C are baby boomers. Many baby boomers were infected with hepatitis C when they were in their teens and twenties. Some may have become infected through blood transfusions or other health care exposures before universal precautions and widespread blood screening began in 1992. Others may have become infected from experimentation with drug use, even if only once decades ago. Because these exposures were often long ago, many baby boomers may not recall — or may be unwilling to discuss — the events that could have placed them at risk. As a result, many have never been tested for hepatitis C.

According to the Centers for Disease Control and Prevention (CDC), 3.2 million U.S. baby boomers are infected with chronic HCV.[3] The agency also estimates that:

  • There are about 17,000 new infections in 2010
  • Blacks are twice as likely to be infected as whites
  • Baby boomers are five times more likely to be infected than other adults; yet, up to 50% of infected baby boomers do not know they have the virus because hepatitis C can damage the liver for many years with few noticeable symptoms
  • Up to 35% of patients are asymptomatic until the onset of advanced liver disease

Until August of 2012, CDC guidelines called for testing only those individuals with certain known risk factors for hepatitis C infection, such as injectable drug use or having had sexual relations with an infected person.  Unfortunately, many baby boomers don’t perceive themselves to be at risk or are too embarrassed to volunteer information about illicit drug use.  Many boomer-aged patients don’t provide the information because more than half of primary care practitioners report that they don’t ask about risk factors![4] In addition, standard, routine tests of liver function likely miss more than half of all cases of hepatitis C infection.

Another reason for under-diagnosis is that early symptoms of newly acquired HCV infection—nausea, fatigue, jaundice, vomiting and joint or abdominal pain—are unlikely to prompt a visit to a health care professional.

As a result, CDC has expanded its risk-based guidelines to include a simple, one-time blood test for all baby boomers (Table 1).[5] For those who test positive, the new, expanded recommendations call for referral to care and treatment and a brief screening for alcohol use, which can accelerate progression of liver disease in those with hepatitis C.

CDC believes that the screening test approach will address the largely preventable consequences of this disease, especially in light of newly available therapies that can purportedly cure up to 75% percent of infections.  The agency estimates that one-time hepatitis C testing of baby boomers could identify more than 800,000 additional people with hepatitis C, prevent the costly consequences of liver cancer and other chronic liver diseases and save more than 120,000 lives.[5]

The Test

HCV testing should be initiated with an FDA-approved test for antibody to HCV (anti-HCV), which are highly sensitive and specific.[5] An HCV point-of-care assay that can provide results in <1 hour is available for clinical use.  An immunocompetent person without risks for HCV infection who tests anti-HCV negative is not HCV-infected and requires no further testing for HCV. Additional testing might be needed for persons who have ongoing or recent risks for HCV exposure (e.g., injection-drug use) and persons who are severely immunocompromised (e.g., certain patients with HIV/AIDS or those on hemodialysis).  A person whose anti-HCV test is reactive should be considered to either 1) have current HCV infection or 2) have had HCV infection in the past that has subsequently cleared. To identify persons with active HCV infection, persons who initially test anti-HCV positive should be tested by an HCV nucleic acid test.

If the Test is Positive

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, you should also evaluate the patient’s level of alcohol use and provide a brief alcohol intervention if clinically indicated.

The good news for people who are newly diagnosed with chronic hepatitis C is the promise of new drugs on the horizon that will make treatment easier and more effective.  Two of them—boceprevir (Victrelis) and telaprevir (Incivek)—are already FDA-approved for use in combination with interferon and ribavirin—both of which require multiple administrations during the day.  But these drugs are expensive (treatment can cost up to $100,000) and are not without risks of their own.[6] Several manufacturers are currently developing once-daily oral protease inhibitors that do not require concurrent administration of interferon and ribavirin.

CDC believes that testing saves lives. CDC estimates that implementing the new testing recommendations could identify 800,000 additional hepatitis C virus infections; providing these patients with appropriate care and treatment could prevent more than 120,000 deaths.[7] The agency also believes that testing is cost-effective. One-time hepatitis C screening for baby boomers, with treatment for those found to be infected is comparable in cost effectiveness to other routine preventive health services, such as screening for cervical cancer or cholesterol screening and treatment.[8]

 

Jill Shuman, MS, ELS
Published on September 4, 2012

 

References

  1. U.S. Centers for Disease Control and Prevention.  Hepatitis C Information for Health Professionals.  http://www.cdc.gov/hepatitis/HCV/HCVfaq.htm#section1
  2. Ly KN, Xing J, Klevens M, et al.  The increasing burden of mortality from viral hepatitis in the United States between 1999 and 2007.  Ann Int Med. 2012;156(4)::271-278.
  3. U.S. Centers for Disease Control and Prevention.  The ABCs of viral hepatitis.  Publication No. 21-1076. August 2012. http://www.cdc.gov/nchhstp/newsroom/docs/ABCs-of-Viral-Hepatitis.pdf
  4. Leverence RR, Williams RL, Pace W, et al.  Context of clinical care: the case of hepatitis C in underserved communities—a report from the Primary Care Multiethnic Network (PRIME Net) Consortium. JABFM 2009;22:638-646.
  5. Smith BD, Morgan RL, Beckett GA.  U.S. Centers for Disease Control and Prevention.  Recommendations for the Identification of Chronic Hepatitis C Virus Infection Among Persons Born During 1945–1965MMWR 2012;61(RR-4);1-36. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6104a1.htm
  6. U.S. Food and Drug Administration.  FDA Drug Safety Communication: Updated information on drug interactions between Victrelis (boceprevir) and certain boosted HIV protease inhibitor drugs.  April 26, 2012.  http://www.fda.gov/Drugs/DrugSafety/ucm301616.htm
  7. CDC fact sheet. Hepatitis C: expansion of testing recommendations, 2012. May 2012. http://www.cdc.gov/nchhstp/newsroom/docs/2012/HCV-TestingRecsFactSheet_508.pdf
  8. McGarry LJ, Pawar VS, Parekh HH, et al. Economic model of a birth cohort screening program for hepatitis C virus. Hepatology. 2012;55:1344–1355.