September 04, 2019 04:32 pm Chris Crawford – More than 4 million people in the United States have a past or current hepatitis C virus infection, and it's the most common cause of death from a reportable infectious disease.
Compounding this, there are now more than three times as many cases of acute HCV infection than there were 10 years ago, and the disease is disproportionately affecting more young people than ever before, especially injection drug users in rural areas.
On the up side, there also now are newer antiviral medications that are safer and more effective in treating patients with HCV infection.
To help address this public health dilemma, the U.S. Preventive Services Task Force on Aug. 27 issued a draft recommendation statement and draft evidence review on screening adolescents and adults for HCV infection.
Based on its review of current evidence, the USPSTF recommends screening for HCV infection in adults ages 18-79 -- a "B" recommendation.
In a recently issued draft recommendation, the U.S. Preventive Services Task Force recommends screening adults ages 18-79 for HCV infection -- a "B" recommendation.
This draft statement updates a 2013 USPSTF final recommendation, expanding the age range for screening for HCV from adults born in 1945-1965 to all adults.
The task force also suggests in the draft recommendation that clinicians consider screening patients who are younger than 18 and older than 79 if they are at high risk for infection.
"Today, more people are infected with hepatitis C than there were a decade ago, but there are now better treatments available," said task force chair Douglas Owens, M.D., M.S., in a news release. "The evidence now shows more people can benefit from screening; therefore, we are recommending to screen all adults ages 18 to 79 for hepatitis C."
This draft recommendation statement updates a 2013 USPSTF final recommendation, expanding the age range for screening for HCV to all adults. The AAFP supported that final recommendation at the time.
The 2013 final recommendation statement called for HCV screening in patients at high risk for infection and one-time screening in adults born between 1945 and 1965.
In the new draft recommendation, the task force also suggests that clinicians consider screening patients who are younger than 18 and older than age 79 if they are at high risk for infection.
The USPSTF commissioned a systematic evidence review to update its previous statement on screening for HCV infection; the new review was similar in scope to the previous one except that it also examined evidence on adolescents.
Since 2013, the prevalence of HCV infection has increased in younger people, the task force found.
Additionally, the USPSTF said the prevalence of HCV infection in adults born between 1945 and 1965 remains relatively high, and prevalence in the elderly will increase as this population ages.
As for treatment, the USPSTF focused on currently recommended direct-acting antiviral regimens.
"The treatment of HCV continues to evolve, resulting in greater benefits and fewer harms than when the USPSTF last considered the evidence," the draft recommendation said. "DAA regimens are of shorter duration with higher rates of sustained virologic response and fewer serious harms than previous treatment regimens."
Clinical trials examining DAA treatment included adults in their early 80s, the task force noted, increasing the evidence base for screening benefit in older adults. That, coupled with limited epidemiologic data on HCV incidence in adolescents younger than 18, led the task force to conclude that broadening the age for HCV screening beyond its previous recommendation could identify infected patients at earlier stages of disease who could greatly benefit from effective treatment before developing complications.
AAFP Commission on Health of the Public and Science member James Stevermer, M.D., of Fulton, Mo., told AAFP News that several factors likely led to the expanded age range in the new draft recommendation -- the dominant one being the development and approval of newer oral DAA agents, which have revolutionized HCV therapy.
"Their high success rate in obtaining a sustained virologic response and excellent tolerability have markedly improved the risk/benefit ratio of therapy," he said. "DAA agents are safer, much better tolerated and more effective than prior therapies. They are taken once daily, and usually obtain SVR within eight to 12 weeks of therapy."
The biggest downside of these medications is the cost -- as much as $100,000 for a course of therapy, Stevermer said.
"While the cost is improving with time, it still can be a limiting factor for some patients, especially those without adequate pharmaceutical coverage," he added.
During the past several years, the incidence of HCV infection has increased in younger adults, said Stevermer, and the USPSTF reasoned that screening that group could prevent the development of complications from HCV infection, including cirrhosis.
"Modeling studies have suggested that screening all adults between 18 and 79 years of age is cost-effective," he said. "This will find more individuals than just screening the current age cohort screened (those born between 1945 and 1965) and is easier to implement than a risk-stratification approach."
Stevermer said most new HCV infections occur in young white people who inject IV drugs and live in nonurban areas. IV drug users are at highest risk for contracting HCV infection, so there may be benefit in identifying and screening those individuals, even if they're younger than 18, he added.
"Up to a third of people under age 30 who use IV drugs have hepatitis C, and this proportion only increases with age," he said. "States that have higher rates of treatment admissions for opioid injection use also tend to have higher rates of acute HCV infection."
And although it takes years to develop the adverse health outcomes of HCV infection, presumably, treatment could prevent the spread of the infection to others, said Stevermer.
"However, there are only limited data about the epidemiology of HCV in adolescents, and not all DAA are approved for those under 18 years of age," he added.
Finally, the draft recommendation statement also addressed HCV infection in pregnant women, but many unanswered questions remain.
"Previous treatments for hepatitis C were teratogenic, and the newer DAAs have not been adequately tested in pregnancy," Stevermer said. "There are limited data suggesting no association of hepatitis C transmission with method of delivery or breastfeeding. However, one study from 2005 found that women who were co-infected with HIV, had membrane rupture of six hours or more prior to delivery, or who had internal fetal monitoring placed had higher rates of HCV transmission."
The USPSTF is accepting comments on the draft recommendation statement and draft evidence review on screening adults for HCV infection until 8 p.m. EDT on Sept. 23. All comments received will be considered as the task force prepares its final recommendation.
The AAFP will review the USPSTF's draft recommendation statement and supporting evidence and will provide comments to the task force. The Academy will release its own recommendation on the topic after the task force finalizes its guidance.