Practice Pearl 1: Pregnancy and Annual Screening for Hepatitis C

2020-03-18 12:54:00
Tags: specialty pharmacy,hepatitis



Experts in the management of hepatitis C provide an understanding for when to screen annually and why pregnant women should be screened. 

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Christian B. Ramers, MD, MPH, AAHIVS: Caroline, I know you have screening of pregnant women. Can you talk about where that fits in? Previously were they considered high risk and if not, why not? How does that fit into the new guidelines?

Caroline Derrick, PharmD, BCPS: I think you really alluded to that. We used to have a unimodal distribution of those infected with hepatitis C, our baby boomer population, because of unregulated tattooing or nonscreened blood prior to '92 or '94. We're having our younger patients infected. This opioid epidemic is really affecting everyone, so a way to catch our younger patients who may be infected would be to screen our pregnant women. 

Pregnant women are coming in, and there are varying governing bodies for recommendations of screening pregnant women, and it's not uniform yet. However, I think we're in the movement to really screen these patients. That's where we can catch some of our younger folks and your young patients. If we do screen them, some of the discussion is that we can't treat them. We can't currently treat pregnant women according to the guidelines. There are some small studies that say that they should do just fine, but currently we're not treating pregnant women. However, we can ensure that we appropriately link them to care and then we can ensure appropriate monitoring for the child. That's a big deal when we're talking about screening for hepatitis C. 

I'm a big advocate for screening our pregnant women to appropriately link them to care. Talk to them about breastfeeding, because they can still breastfeed their child unless they have cracked nipples or there's visible blood. There are nuances with pregnant women, so screen them. And the guidelines are catching up and recommending to screen these women. 

Christian B. Ramers, MD, MPH, AAHIVS: I think for the CDC and the US Preventive Services Task Force, it's universal onetime screening for everyone, but then for pregnant women, it's with each pregnancy to undergo a repeat screening. 

Caroline Derrick, PharmD, BCPS: Correct.

Christian B. Ramers, MD, MPH, AAHIVS: Bhavesh, if I could just ask, what are the implications of this shift from age-based or baby boomer birth cohort screening plus risk factors toward a universal opt-out situation? What are the implications for that change, do you think?

Bhavesh Shah, RPh, BCOP: I don't know. I think that would be significant. We would be able to capture those patients who we haven't been able to currently with the current screening methods that we have. We implemented universal screening across our ED [emergency department], across our primary care center.

We have to be mindful of where we implement screening, because as you mentioned, there has to be appropriate care that these patients need to be placed in and appropriate linkage to care that needs to happen. That really drives the decision on where you implement screening. We partnered with a lot of the FQHCs [Federally Qualified Health Centers] across the country, about 50 of them, and had identified that of 200,000 patients who had reported substance-use disorder, only 30% were screened. That's a significant unmet need for this patient population that we know has a higher risk. I think that there is a push toward more universal screening at least once for a lot of these patients.

Christian B. Ramers, MD, MPH, AAHIVS: I keep bringing up this 50% of people that don't know that they have hepatitis C. I see patients every week that either were not screened by their primary care physician or were screened and just really not pushed toward treatment. They say, "Well, how did this cirrhosis develop?" It develops slowly. Not only screening, but you're right, getting people into care and getting them treated are important as well.