Screening Specific Populations for HCV
HCV eradication cannot begin until an effective case identification strategy is in place. The Centers for Disease Control and Prevention (CDC) and the US Preventive Services Task Force have recently recommended 1-time HCV screening for all Americans born during 1945-1965 ("baby boomers") to reduce HCV-related morbidity and mortality.
US veterans. US veterans in Department of Veterans Affairs care typically have a higher HCV infection rate than the general public -- 6.1% for veterans vs 2.5% for all Americans. Backus and colleagues assessed the extent of complete birth cohort screening for HCV among veterans and estimated the potential clinical impact. Of 5,500,392 veterans, 55% (2.9 million) were screened for HCV at least once (Table).
Table. Anti-HCV and HCV Prevalence, by Year of Birth
|Proportion of Birth
For those in the 1945-1965 birth cohort, HCV infection prevalence rates decline according to the year of first screening. In veterans first screened between 1999 and 2003, the prevalence fell sharply from 33.2% to 10.3%. Thereafter, prevalence rates fell more gradually, from 9.5% of those screened in 2004 to 5.7% in 2012.
The observation that anti-HCV and HCV infection prevalence are markedly elevated among those born during 1945-1965 compared with those born before or after this period supports the recommended emphasis on birth cohort testing. The investigators postulated that unless the disease is recognized and treatment considered, 1.7 million veterans with HCV are at risk for cirrhosis and 400,000 for hepatocellular carcinoma; therefore, more than 1 million individuals are at risk for death from HCV-related disease.
Emergency department patients. Galbraith and colleagues screened for HCV in baby-boomer patients presenting to an urban academic hospital emergency department (ED). They identified a high prevalence of chronic HCV infection among previously unaware baby boomers, with approximately 1 of every 8 screened ED patients exhibiting positive reactivity. These pilot results highlight the ED as an important venue for HCV screening.
Pregnant women. The American College of Obstetricians and Gynecologists recommends HCV screening only in pregnant women "with significant risk factors." Chen and colleagues estimated the potential for missed diagnosis under current targeted screening practices and evaluated the correlations between chronic HCV infection and pregnancy outcomes. A substantial proportion (72%) of pregnant women with chronic HCV had no traditional, codeable risk factors, and thus could be overlooked under the present targeted screening guidelines.
HCV-positive women have a significantly increased risk for adverse pregnancy outcomes, including early or threatened labor, pulmonary embolism, antepartum hemorrhage, and poor fetal growth. The investigators suggested that expansion of HCV screening practices in pregnant women should be considered, especially if emerging therapeutic strategies are safer for use in pregnancy than IFN- and ribavirin-based regimens.
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