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Hepatitis C Screening Updated

Part of the reason that I love medicine is that processes are always changing, and new evidence is continuously evolving to help us better care for our patients. I joined Medgeeks in October 2017 and in my short 2.5 years here, much of the work I have done has already changed so much. In fact, my very first article was about this very topic; Hepatitis C Screening in Adults, also check-out my newest article on LFT's. Today we are going to discuss a new and very interesting clinically relevant update to the hepatitis C screening guidelines.

 

USPSTF screening guidelines

 

In our private board review, a question that I have traditionally saved for our GI lecture, is always about Hepatitis C screening. So far, and both sessions we have covered this and I have been surprised to find that many students are not aware of the USPSTF screening guidelines for Hepatitis C. Many students will comment on the usual risk factors for acquiring Hepatitis C including:

  • Sketchy tattoo parlors
  • IV drug users
  • sexual promiscuity

However, many miss the mark for the broader population that needs attention.

 

Old Guidelines

 

Before recently, the correct answer for Hepatitis C screening also included the so called “baby boomers”, including anyone born from 1945-1965, regardless of overall risk profile. But today, we will review the newest guidelines so you can be on the forefront of clinical medicine. If you are interested in other cutting-edge guidelines, head over to our other venture for a free trial of, “In the Know” with my colleague Joe Rad.

 

Newest guidelines (2020) - Who should we screen?

 

Just recently, the USPSTF and JAMA have released new guidelines for clinicians screening for Hepatitis C. The argument is that Hepatitis C is not only “the most common blood borne pathogen in the US”, but is also more deadly than any of the first 60 most common blood borne diseases….combined. (JAMA/UPSTF, 2020). This statistic even includes HIV! Incredible to even think about, that there could be many patients in your practice presenting for physical exams and blood pressure checks, infected with Hepatitis C and entirely unaware.

 

Why the update?

 

As a result of the previous screening update, which was published back in 2013; more than 1000 new cases of Hepatitis C have been diagnosed in previously undiagnosed populations. Importantly, these may have been undiagnosed for years without a simple screening. In my practice, I have picked up 2-3 new cases of Hepatitis C just by offering screening to those that had previously fit the category. As a result, the new guidelines indicate that all US adults age 18 to 79, even if asymptomatic, should be screened for Hepatitis C. This is a grade B recommendation.

 

The opioid epidemic and its correlation to hepatitis C

 

I can’t say I’m not particularly surprised by this new recommendation, to be honest. In my observation, the growth of the opioid epidemic has been correlated with increasing Hepatitis C cases, particularly in young people. According to their 2020 article, JAMA and USPSTF, indicate that 44,700 new cases of hepatitis C were diagnosed in 2017 alone, with an estimate overall that there could be millions of undiagnosed cases in the U.S.

 

How do we screen patients?

 

Screening is as easy as taking blood. Obviously, the clinician should have a discussion with the patient regarding the indications, importance, and possible results of the test. In my practice, our nurse starts the conversation and can order the lab test if necessary. If the patient has more questions or wants to discuss further, I certainly can discuss with them. Many patients opt out of Hepatitis C screening, which is perfectly fine as long as they are aware of the risks by not screening and can give their informed consent. The attitude of many of my patients is that if they are already going for lab work, might as well add it on.

 

Initial versus confirmatory testing

 

The blood sample is an IgG/IgM initially, which is followed by a polymerase chain reaction test as a confirmatory. Many labs will do a reflex to a viral load and some labs will even do a genotype if available. In our case, our lab will run a viral load, but an additional test needs to be done to determine the genotype.

 

How often do I need to screen?

 

In many cases, your average patient will not be addicted to heroin or getting tattoos routinely at sketchy tattoo parlors, so a one-time screening is usually sufficient. In the case where a patient is actively using IV drugs or is felt to be at increased risk by the clinician, periodic testing every few months is reasonable.

What is the goal of screening?

The goal of screening is to identify Hepatitis C early, as we know that there is a very long asymptomatic period prior to patients developing symptoms of cirrhosis. The more patients screened, the better care that can be provided, as many cases of Hepatitis C are curable with medications such as Harvoni.

 

References

JAMA and USPSTF (2020). Screening for Hepatitis C infection in Adolescents and Adults. Date of access 28 March 2020.

This article or blog post should not be used in any legal capacity whatsoever, including but not limited to establishing standard of care in a legal sense or as a basis of expert witness testimony. No guarantee is given regarding the accuracy of any statements or opinions made on the podcast or blog.