Best Practices for the Management of Hepatitis C - Episode 7
Practice Pearl 1: Screening Recommendations for Hepatitis C
A review of the current screening recommendations for hepatitis C by experts in the field of hepatitis C.
- Complications of Hepatitis C: Cirrhosis and Decompensated Cirrhosis
- Complications of Hepatitis C: Hepatocellular Carcinoma
Christian B. Ramers, MD, MPH, AAHIVS: In the first part of this section, we’re going to talk about screening tests. There’s been a lot of change in this area. Chris, can you go through what the older screening recommendations were and where we are in terms of moving? I know there are a couple of different bodies that are weighing in on this.
Christopher Hulstein, PharmD, CSP: As I previously alluded to, a lot of the emphasis was placed on the baby boomer population. Following the NHANES [National Health and Nutrition Examination Survey] database, we did find that those patients who were born between 1945 and 1965 were at very high prevalence of having hepatitis C. But that information is flawed because there were a lot of at-risk patients who were excluded from that survey.
Until very recently, the recommendation was specific to the baby boomer population and patients who were at risk of getting hepatitis C: patients who had ever been on long-term hemodialysis, patients with IV [intravenous] drug use, patients who snort illicit drugs, men who have sex with men, patients who have ever been incarcerated. Now there’s this shift in paradigm as we see a shift in the epidemiology to screening essentially any patient who’s 18 or older at least 1 time within their life.
What we’re starting to see with the opioid epidemic is that there’s now a huge shift in where hepatitis C hits. It’s largely in a much younger population, even in rural areas. I believe it’s mostly Caucasian, young adults who are using in rural areas. In my practice I’ve seen a number of younger patients who have been exposed to the virus as well through that particular paradigm, so a lot of the focus is starting to get away from the complicated screening risk factors and just doing a little more universal screening overall.
These are currently taking up in the AASLD [American Association for the Study of Liver Diseases] and IDSA [Infectious Diseases Society of America] guidelines. It is a grade B recommendation to screen patients 18 and older at least once. The US Preventive Task Force has draft guidelines, as does the CDC, and it’s all based on a couple of studies that independently found that it would be cost effective to screen these patients 18 and older at least once and then annual screening for high-risk patients. Those high-risk patients are those who are IV drug users, those who do intranasal drug use, and then men who have sex with men as well, simply because they’re at a high risk for reinfection. Even if you’re treated, you can still be reinfected in the future, and we do want to catch those patients as well.
Christian B. Ramers, MD, MPH, AAHIVS: Before we go to the universal screening recommendations, which I think is a very exciting way that we’re going to reach that 50% of undiagnosed people, let’s talk about the baby boomer recommendation. What is it about being a baby boomer that magically makes you higher risk of having hepatitis C?
Christopher Hulstein, PharmD, CSP: That’s a good question. I think prior to the 1980s, we really didn’t know hepatitis C was a thing. We didn’t have it identified. We kind of had it in other hepatitis types of infection that we called…
Caroline Derrick, PharmD, BCPS: Non-A, non-B.
Christopher Hulstein, PharmD, CSP: Non-A, non-B hepatitis. The baby boomer population lived through the 1960s and Woodstock and all that. There was a lot of needle sharing during those times. Aside from that, blood product oftentimes was infected with hepatitis. That’s probably 1 of the more common reasons that I have a baby boomer in my clinic, who may have had a blood transfusion prior to the 1990s or received blood product in the 1980s or something like that. Prior to those time periods, that blood product could have been infected with hepatitis C, and it was administered to that population. They naturally just have a couple of areas where they’re at a higher risk of getting that infection.
Christian B. Ramers, MD, MPH, AAHIVS: Not to mention it’s really any blood exposure, so it could be dental work or tattooing.
Christopher Hulstein, PharmD, CSP: Exactly.
Christian B. Ramers, MD, MPH, AAHIVS: I think tattoo parlors really were under local jurisdiction and regulation surrounding not reusing ink and that kind of thing. It was not until 1990s or later that that happened.