Birth Cohort Screening for Chronic Hepatitis During Colonoscopy Appointments

Dawn M Sears MD; Dan C Cohen MD; Kimberly Ackerman DO; Jessica E Ma; Juhee Song PhD

Disclosures

Am J Gastroenterol. 2013;108(6):981-989. 

In This Article

Abstract and Introduction

Abstract

Objectives: More than 70% of infections with hepatitis C viruses (HCV) occur among people born between 1945 and 1965 (baby boomers). The US Centers for Disease Control estimate that 70% of people with chronic hepatitis are not aware that they are infected with a virus. We performed a prospective trial to determine whether people born during this time period would accept testing for chronic viral infection (hepatitis B virus (HBV) and HCV) during routine colonoscopies. We also evaluated acceptance and efficacy of screening for immunity to hepatitis A (HAV) and B viruses.

Methods: During a 3-month period, 500 people, 50–65 years old, who received a colonoscopy were offered a test for viral hepatitis. Patients answered questions about vaccination, exposure, diagnoses, and risk factors related to viral hepatitis, and blood samples were collected. Patients who tested positive for antibodies to HCV or hepatitis B surface antigen (HBsAg) were contacted for further testing and possible therapy. Patients without immunity to HAV or HBV were offered vaccinations.

Results: Three hundred and seventy-six people (158 men) agreed to be tested. Four were found to have antibodies against HCV and one had detectable virus. None of the patients tested positive for HBsAg; 136 (36%) had at least one risk factor for chronic hepatitis and 31 (8%) had multiple risk factors. Three hundred and fifteen patients (84%) were not immune to HAV, HBV, or both viruses.

Conclusions: It is possible to screen patients for viral hepatitis during visits for routine colonoscopy. This approach can identify individuals with undiagnosed chronic HBV and HCV infections who could benefit from education, vaccination, or therapy.

Introduction

Chronic viral hepatitis is a major silent epidemic in the United States. Over 5 million Americans have chronic hepatitis C virus (HCV) or hepatitis B virus (HBV) infection.[1,2] The Center for Disease Control (CDC) estimated that over 70% of chronic HCV infection is undiagnosed. It is estimated that 1 in 30 Americans born between 1945 and 1965, "the Baby Boomers", are infected with HCV.[3] Therefore, the CDC is now recommending one time screening of all baby boomers for chronic hepatitis C. HCV infection now supersedes HIV as a cause of death in the United States. Mortality from chronic HCV infection is estimated to double by the year 2020 and triple by the year 2030.[4,5] Although required HBV vaccinations have decreased the prevalence of HBV among children, possibly due to immigration patterns, the prevalence of HBV among adults in the United States has remained essentially unchanged at 0.27%.[2]

Previously, it was recommended to screen only high-risk individuals (with the most common risk factor for HCV being intravenous (IV) drug use) or patients with abnormal liver tests. To date, the majority of community hepatitis screening programs have focused on drug treatment centers, homeless shelters, and prisons.[6–11] These patients generally have poor access to healthcare and are less invested in their health, making treatment and/or follow-up difficult. More importantly, targeted screening programs focusing on high-risk populations fail to identify the majority of undiagnosed chronic viral hepatitis infections, 66–70% of which are found in Americans born between 1945 and 1965. Baby boomers commonly contracted HCV from pre-1992 blood transfusions or past IV drug use.[2] Quickly finding and treating patients in this age range is imperative as patients older than 65 years are more likely to develop severe fibrosis and are four times less likely to complete antiviral therapy due to adverse side effects.[12–14]

As with chronic viral hepatitis, acute viral hepatitis due to hepatitis A virus (HAV) and HBV represents a large epidemiologic problem. Acute HAV infection is the leading cause of acute hepatitis worldwide. Adults who become ill with this food-borne infection miss an average of 30 days of work due to jaundice.[15] Despite widespread availability of HAV and HBV vaccinations, only 10–50% of adults have antibodies against these viruses.[16–19] Therefore, there is a significant unmet need to systematically incorporate risk assessment, screening, vaccination, and treatment of viral hepatitis into the adult health-care delivery system.

Gastroenterologists are in a distinctive position as they are both experts on viral hepatitis and perform screening colonoscopies. Currently, routine screening colonoscopies are recommended for individuals starting at age 50, with recommended follow-up colonoscopies at 5- or 10-year intervals in the majority of cases.[20] Furthermore, patients who present for screening colonoscopies generally have access to healthcare and are often health-insured. Two recent studies have found that birth cohort screening for viral hepatitis is cost effective regardless of risk factors.[21,22] This represents a unique opportunity for gastroenterologists to conduct screening for viral hepatitis on baby boomers when they present for screening colonoscopies.

Our study sought to evaluate the feasibility and patient acceptance of screening baby boomers who present for colonoscopy for chronic HCV and HBV infection, and HAV and HBV immunity. Additionally, we assessed the effectiveness of this screening method in achieving substantial patient follow-up for the treatment of chronic hepatitis and vaccinations to prevent acute hepatitis.

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