Anyone born between 1945 and 1965 should be tested for hepatitis C virus (HCV), according to new guidance released by the US Centers for Disease Control and Surveillance (CDC).
The guidance quotes research showing that prevalence of hepatitis C is significantly higher in this age group – the so-called “baby boomer” generation – than in other age groups. Current risk-based screening strategies mean that many infections remain undiagnosed and therefore untreated, leading to a high risk of liver cirrhosis, liver cancer and death.
According to the new guidelines, individuals diagnosed with hepatitis C should be counselled about their alcohol consumption.
Published simultaneously in the August 17th edition of Morbidity and Mortality Weekly Report and online by Annals of Internal Medicine, the new CDC guidelines note that “the success of risk-based strategies has been limited.”
It is estimated that between 2.7 and 3.9 million people in the US are infected with hepatitis C. Incidence of the infection was highest in the 1970s and 1980s, reaching approximately 230,000 infections each year at the end of this period. Injecting drug users and recipients of blood products had the greatest risk of infection with hepatitis C.
Universal screening of blood products for hepatitis C was introduced in 1992 leading to a fall in incidence. There were an estimated 17,000 new infections in 2010.
Previous CDC guidelines concerning screening for hepatitis C have been risk based. Those issued in 1998 recommended testing for people with a history of injecting drug use, as well as those who had received blood products and organs before 1992, the children of mothers with hepatitis C, and healthcare and other workers who had had occupational injuries that may have involved exposure to the virus. The guidelines were updated in 1999 to recommend testing for all HIV-positive people.
Nevertheless, between 45% and 85% of all hepatitis C infections in the US are still undiagnosed.
This high rate of undiagnosed infections is contributing to the 50% increase in hepatitis C-related mortality seen in the US between 1999 and 2007. The number of deaths in the US due to hepatitis C now exceeds the number caused by HIV. The longer someone is infected with hepatitis C, the greater the risk of developing liver cirrhosis and liver cancer. People infected with the virus in the 1970s and 1980s now have a significant risk of serious hepatitis C-related disease.
Given these concerns, the CDC convened a panel of specialists to consider if blanket testing of individuals born between 1945 and 1965 was justified. The panel included experts in hepatitis C prevention, epidemiology, education, training, research and development, as well as guideline development.
Before developing their guidance, the panel conducted a meta-analysis of studies published between 1995 and 2012 looking at the prevalence of hepatitis C in different age groups and the benefits of testing and treatment.
This showed a significantly higher hepatitis C prevalence in the baby boomer generation (3.25%) compared to adults aged 20 years or older who were born outside these years (1%).
Their literature search showed that diagnosis of hepatitis C outweighed any potential risks.
“Certain harms (that is, worry and anxiety while waiting for test results, insurability, liver biopsy complications and severe adverse events during treatment) can be detrimental to patients,” acknowledge the authors. “The benefits associated with diagnosis and effective treatment include SVR [sustained virological response, the aim of hepatitis C therapy], which is associated with reductions in HCC [hepatocellular carcinoma, liver cancer] and all-cause mortality.”
Their analysis showed that triple-drug treatment for hepatitis C achieved a sustained virological response in approximately 70% of mono-infected patients (people who only have hepatitis C, as opposed to people with hepatitis C and HIV, which is sometimes referred to as 'co-infection'). Compared to untreated patients, individuals who achieved a sustained virological response reduced their risk of liver cancer by 75% and all-cause mortality by 30%.
The new guidelines also recommend that all patients diagnosed with hepatitis C should be asked about their alcohol use and if appropriate be given support to reduce their alcohol consumption. A literature review showed that a brief intervention led patients to reduce their alcohol consumption. Alcohol is a recognised risk factor for the progression of hepatitis C-related liver disease.
“Although the screening and intervention may be uncomfortable or cause anxiety, the benefits of alcohol reduction for persons with HCV infection outweigh those harms.”
Smith BD et al. Hepatitis C virus testing for persons born during 1945 to 1965: recommendations from the Centers for Disease Control and Prevention. Ann Intern Med, 157, online edition, 2012 (click here for the free paper).
Smith BD et al. Recommendations for the identification of chronic hepatitis C virus infection among persons born during 1945-1965. MMWR, 61:4, 2012 (click here for a free copy).