Hepatitis C: Screening, Identification, and Care

Digestive Disease Week (DDW) 2015

Nancy S. Reau, MD; Lauri R. Graham

Disclosures

July 21, 2015

In This Article

Editor's Note: Following this year's Digestive Disease Week (DDW) meeting, Medscape spoke with Nancy S. Reau, MD, associate professor of medicine and staff physician in the Department of Gastroenterology at University of Chicago, about some of the issues and challenges that continue to exist in the treatment of patients with hepatitis C, as well as strategies for improvement.

Screening

Medscape: Can you briefly comment on the scope of hepatitis C, including its prevalence and incidence and who is most at risk?

Dr Reau: We used to think that the incidence and prevalence of hepatitis C were relatively stable, with the rate of new infections decreasing significantly after screening blood products and because universal precautions lowered iatrogenic exposure. Yet, up to two thirds of chronically infected individuals are unaware of their disease status.

Although physicians do recognize the risk factors associated with transmission, we haven't done a very good job of screening individuals at the highest risk for hepatitis C—those who have been exposed to other people's blood, whether it's through transfusions prior to 1992, tattooing, IV drug use and needle sharing, or being in close contact, such as the prison population or institutionalized patients.

The Centers for Disease Control and Prevention (CDC) has done a great job of looking at where the number of individuals with hepatitis C exposure concentrate, and they found that the birth cohort (individuals born between 1945 and 1965) is the way to identify about 75% of hepatitis C–infected Americans. However, this isn't going to be everybody, and if we concentrate only on the birth cohort, we're going to miss a lot of screening opportunities.

So, as clinicians, we have to ask difficult questions to our patients, about whether they have been in prison or used IV drugs, or have been involved in a high-risk sexual relationship, for example. Tattooing is now identified as a true risk factor. Previously it was difficult to isolate from other high-risk behaviors, but now, tattooing is so common, and individuals with tattoos may not have any other risk. Although I think tattoos can be done safely, the risk for exposure to hepatitis C is higher if tattooing is not in parlors with controlled circumstances.

We also recognize that there's an acute increase in hepatitis C in younger individuals. In fact, the CDC recently alerted Kentucky, Tennessee, Virginia, and West Virginia about this increase in infections.

So, while it's nothing like it used to be, there are still people who engage in high-risk behaviors and are still at risk for hepatitis C, and they need to be screened.

Medscape: You mentioned the birth cohort screening recommendation by the CDC. In your opinion, are patients routinely being screened, and do you think it has been effective? Are there ways in which it could be improved?

Dr Reau: Not every question has a straightforward, easy answer. There are absolutely places where birth cohort screening has been effectively implemented. But it's not 100% by any means, so there is room for improvement.

There are a lot of creative ways that have been used successfully. One is an electronic medical record (EMR) alert. EMR users may ignore an alert, so one strategy I have heard was that if you dismiss the alert, it automatically orders the test in a patient who has not had it done. Otherwise, if you do not want to do the test, then you have to opt out and say why you are opting out—for example, the patient has already been screened in another location. This creates more work after seeing the alert if you decide not to screen the patient.

Another way is screening at the time of colonoscopy. Hepatitis C antibody tests that reflex to confirmation (or automatically trigger a hepatitis C PCR when they are positive) can improve efficiency and then remove the bottleneck to communicating results and linking to care.

I think the point-of-care models (when everything is done at the same appointment) and places where screening, communication, and treatment can all be performed in the same location are other effective strategies. This has been effective in needle exchange programs, sexually transmitted disease clinics, and emergency rooms.

There are also nonphysician models. A nurse-led care model was very successful in screening patients at federally qualified health centers in Philadelphia.[1]Not only did screening take place in the majority of eligible patients, but confirmatory testing and communication of results were also very high (around 90%). Another way is to pair medical navigators with at-risk patients to ensure not only screening but also follow-up care.

Screening means nothing if you can't communicate the results to the patients and then link them to the next step in their treatment.

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