Laird Harrison

October 16, 2017

CHICAGO — In response to an increase in the incidence of hepatitis C infections, which tripled from 2010 to 2015, the Centers for Disease Control and Prevention (CDC) and the US Preventive Services Task Force (USPSTF) are considering augmenting their recommendations for screening.

"We really have to work together to see how we can expand testing in the future to move along with the changes in epidemiological trends," said John Ward, MD, from the division of viral hepatitis at the CDC.

After decades of decline, the incidence of the disease is rising, particularly in indigenous American and non-Hispanic white people, Dr Ward reported here at the International Conference on Viral Hepatitis 2017.

The highest incidence is in nonurban areas — particularly in states in the Appalachian, Midwestern, and New England regions — in people 20 to 29 years of age, followed by people 30 to 39 years of age.

This opioid crisis that we are experiencing in the United States is the main driver of increased hepatitis C incidence in this country.

"This opioid crisis that we are experiencing in the United States is the main driver of increased hepatitis C incidence in this country," said Dr Ward.

In one study, 77% of people infected with acute hepatitis had injected drugs, and abuse patterns suggest that the initiation of illegal drug use began with prescription opioid misuse, he explained.

A change in recommendations could have a big impact, in part because USPSTF recommendations typically drive payers' decisions about whether to cover the costs of tests, said Dr Ward. The USPSTF is currently seeking comments on its draft research plan for the screening of adolescents and adults for hepatitis C.

Current Guidelines Target Baby Boomers

Currently, both the CDC and the USPSTF recommend screening baby boomers (people born from 1945 to 1965) and people with specific risk factors for hepatitis C. During those years, the virus spread most rapidly because injections became common but the virus had not yet been identified and disposable syringes were not in wide use.

Of the 3.5 million Americans living with hepatitis C, 81% are baby boomers, and 70% of those have moderate to severe liver disease. Deaths from the virus now exceed deaths from all other infections tracked by the CDC.

So it makes sense to test baby boomers, and a recommendation based on birth year carries less stigma than one based on behavior, said Dr Ward.

In addition, the CDC recommends testing people who have injected drugs, have HIV, have received clotting factor concentrates produced before 1987, have ever been on long-term hemodialysis, have persistently abnormal alanine aminotransferase levels, have been notified that they received blood from a donor who later tested positive for hepatitis C, know they have been exposed to hepatitis C, or have received a transfusion of blood, blood components, or an organ transplant before July 1992.

The 2012 CDC recommendation to test baby boomers coincided with the advent of drugs that can clear the infection in about 90% of patients.

In settings where the screening recommendation has been fully implemented, it has been successful. For example, after screening 78.8% of baby boomer veterans, the US Department of Veterans Affairs estimates that it has diagnosed 90% of cases. So far, about 87,000 veterans have been treated, and about 58,000 have been deemed eligible for treatment but are still untreated.

To respond to epidemiologic trends, the CDC is looking for ways to improve testing in people who inject drugs.

Targeting Drug Users

In a study of people who inject drugs, 70% reported that they had been tested for hepatitis C, and 41% reported being told that their test was positive. In contrast, about 88% reported being tested for HIV, and 9% of those tests were positive (MMWR Surveill Summ. 2014;63:1-51).

We need to improve testing in people younger than the baby boomers, Dr Ward said. "But do you try to improve testing where these younger individuals receive care and you can intersect with them? Or do you do a more general recommendation, like the birth cohort and try to capture them in that fashion?" he asked.

Screening can be offered in emergency departments, where hepatitis C is prevalent, but such tests are not typically reimbursed, and patients who test positive must be referred for treatment, meaning few of those who test positive in this setting receive care.

Studies have shown that 12% to 48% of the prison population is infected with hepatitis C. The USPSTF recommends screening people with a history of incarceration, but only 12 states adhere to that guideline.

"It's a big challenge," said Dr Ward. "You have 50-plus prison systems, and trying to get all of them to follow a recommendation is really, really difficult."

Drug treatment centers offer another opportunity, he pointed out. More opioid treatment programs are offering screening for hepatitis C than in the past, but more are also referring people for testing offsite, he reported. "And, more often than not, people fall out in that process."

One 2013 study found that the test would be cost-effective in a population with a prevalence of at least 0.84 (Clin Infect Dis. 2013;56:1382-1393). The cost-effectiveness might be even better now because the cost of treatment has dropped.

While we seek to expand testing, we have to keep in mind that we have to have the services there so that people benefit from that testing information.

But testing must be coupled with treatment, Dr Ward stressed. "While we seek to expand testing, we have to keep in mind that we have to have the services there so that people benefit from that testing information."

To save costs, many states impose onerous restrictions on treatment, he explained. There are currently 10 lawsuits seeking to overturn these restrictions.

That is a key consideration, said Arlene Seña, MD, from the University of North Carolina at Chapel Hill.

"With any screening recommendation, you have to look at downstream effects," she told Medscape Medical News. "You really want the end result to be a cure."

Finding out which patients inject drugs is particularly challenging. "Some physicians are under pressure to see a lot of patients, and not all doctors are trained to ask questions in a nonjudgmental fashion," she pointed out.

Dr Ward and Dr Seña have disclosed no relevant financial relationships.

International Conference on Viral Hepatitis (ICVH) 2017. Presented October 9, 2017.

Follow Medscape Gastroenterology on Twitter @MedscapeGastro and Laird Harrison @LairdH

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