In the absence of a vaccine to counter the spiraling numbers of infections caused by hepatitis C virus -- the most common chronic bloodborne pathogen in the United States -- HCV takes an immense toll, with nearly 45,000 acute cases occurring each year,(www.cdc.gov) according to CDC estimates. Most of those infected are asymptomatic or have only mild symptoms and don't seek treatment.
Although the infection spontaneously clears in some who contract it, in about 75% to 85% of cases, acute infection progresses to chronic disease,(www.cdc.gov) which can have serious hepatic consequences. So, timely detection of the virus is key to optimizing patient outcomes. To that end, the CDC has announced it intends(www.regulations.gov) to expand its current recommendations for HCV screening and is seeking public comment on the proposed changes.
In a 2012 Morbidity and Mortality Weekly Report,(www.cdc.gov) the agency recommended a birth cohort approach to screening, calling for one-time screening with anti-HCV antibody testing for all adults born from 1945 through 1965 regardless of whether specific HCV risk factors are present.
- The CDC has announced it intends to expand its current recommendations for hepatitis C virus testing and is seeking public comment on the proposed changes.
- Essentially, the agency is calling for universal HCV screening for all adults 18 and older at least once in their lifetime and for all pregnant women during each pregnancy.
- Comments on the CDC's proposed changes will be accepted through 11:59 p.m. on Dec. 27.
That recommendation, in turn, built on the risk-based testing schema(www.cdc.gov) the agency outlined in 1998. That earlier MMWR recommended routine testing for current or past injection drug users, including those who injected only once or a few times many years earlier, and for people with certain medical conditions, such as those who
- received clotting factor concentrates produced before 1987;
- were ever on long-term hemodialysis;
- have persistently abnormal alanine aminotransferase levels;
- have HIV infection; or
- were prior recipients of transfusions or organ transplants, including people who were notified that they received blood from a donor who later tested positive for HCV infection and those who received a transfusion of blood or blood components or an organ transplant before July 1992.
In addition, HCV testing based on a recognized exposure is recommended for health care personnel, emergency medical services providers and public safety workers after needle sticks, sharps or mucosal exposures to HCV-positive blood, as well as for children born to HCV-positive women.
If the anti-HCV antibody test yields a positive screening result, current infection should be confirmed with a qualitative HCV RNA test. In patients with confirmed HCV infection, quantitative HCV RNA testing and testing for HCV genotype is recommended. Management is based on genotype, disease severity, comorbidities and other factors.
Up for Consideration
The CDC now proposes to take a more inclusive approach to HCV testing. Specifically, the agency is considering broadening its recommendations to call for universal hepatitis C screening for
- all adults 18 and older at least once in their lifetime, except in settings where the prevalence of HCV infection (as determined by HCV RNA-positivity) is less than 0.1%; and
- all pregnant women during each pregnancy, except in settings where HCV prevalence is less than 0.1%.
The agency is also recommending one-time hepatitis C testing, regardless of age or setting prevalence, to include people who have the following recognized conditions or exposures:
- HIV infection;
- a history of injecting drugs and sharing needles, syringes or other drug preparation equipment, including those who injected once or a few times many years ago;
- selected medical conditions, including anyone who ever received maintenance hemodialysis and those with persistently abnormal ALT levels;
- certain recipients of transfusions or organ transplants, including people who received clotting factor concentrates produced before 1987 or a transfusion of blood or blood components or an organ transplant before July 1992, and people who were notified that they received blood from a donor who later tested positive for HCV infection;
- health care, emergency medical and public safety personnel after needle sticks, sharps or mucosal exposures to HCV-positive blood; and
- children born to mothers with HCV infection.
Furthermore, the CDC recommends routine periodic testing for people with ongoing risk factors for as long as those risk factors persist. This would pertain to
- people who currently inject drugs and share needles, syringes or other drug preparation equipment; and
- people with selected medical conditions, including those who have ever received maintenance hemodialysis.
Finally, the agency proposes that any person who requests hepatitis C testing should receive it, regardless of disclosure of risk, because many people may be reluctant to disclose stigmatizing risks.
It's worth noting that the CDC's proposed changes are largely consistent with a draft recommendation statement(www.uspreventiveservicestaskforce.org) the U.S. Preventive Services Task Force issued in September that recommended screening all adults ages 18 to 79 for HCV infection, including pregnant women. The draft statement 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.
That's a significant departure from the USPSTF's 2013 final recommendation statement,(www.uspreventiveservicestaskforce.org) which called for HCV screening in patients at high risk for infection and one-time screening in adults born between 1945 and 1965. The AAFP supported the task force's final recommendation at that time.
The Academy is reviewing the latest USPSTF draft recommendation and will update its own HCV recommendations after the task force publishes its final recommendation statement.
Meanwhile, comments on the CDC's proposed changes will be accepted through 11:59 p.m. on Dec. 27. Go online to comment.(www.regulations.gov)
Related AAFP News Coverage
Draft Recommendation Statement
USPSTF: Screen Adults 18-79 for Hepatitis C Infection
More From AAFP
American Family Physician: Diagnosis and Management of Hepatitis C