Hepatitis C Virus Infection in Adolescents and Adults: Screening -- Adults aged 18 - 79 years


General

Grade: B The USPSTF recommends the service. There is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial. Offer or provide this service.

Specific Recommendations

The USPSTF recommends screening for hepatitis C virus (HCV) infection in adults aged 18 to 79 years. 

Frequency of Service

One-time screening for most adults. Periodically screen persons with continued risk for HCV infection (eg, persons with past or current injection drug use). There is limited evidence to determine how often to screen persons at increased risk. 

Risk Factor Information

Asymptomatic adults aged 18 to 79 years (including pregnant persons) without known liver disease.  The USPSTF also suggests that clinicians consider screening persons younger than 18 years and older than 79 years who are at high risk for infection (eg, those with past or current injection drug use). 


Clinical

Practice Considerations

Patient Population Under Consideration

This recommendation applies to all asymptomatic adults aged 18 to 79 years without known liver disease.

Assessment of Risk

Although all adults aged 18 to 79 years should be screened, a number of risk factors increase risk. The most important risk factor for HCV infection is past or current injection drug use. In the US, recent increases in HCV incidence have predominantly been among young persons who inject drugs (PWID).19 Approximately one-third of PWID aged 18 to 30 years are infected with HCV, and 70% to 90% of older PWID are infected.9 Clinicians may want to consider screening in adolescents younger than 18 years and in adults older than 79 years who are at high risk (eg, past or current injection drug use).

Pregnant adults should be screened. HCV prevalence has doubled in women aged 15 to 44 years from 2006 to 2014.11011 From 2011 to 2014, 0.73% of pregnant women tested had an HCV infection, with a 68% increase in the proportion of infants born to HCV-infected mothers.110 Approximately 1700 infected infants are born annually to 29,000 HCV-infected mothers.111 Because of the increasing prevalence of HCV in women aged 15 to 44 years and in infants born to HCV-infected mothers, clinicians may want to consider screening pregnant persons younger than 18 years.

Screening Tests

Screening with anti-HCV antibody testing followed by polymerase chain reaction testing for HCV RNA is accurate for identifying patients with chronic HCV infection.9 Currently, diagnostic evaluations are often performed with various noninvasive tests that have lower risk for harm than liver biopsy for diagnosing fibrosis stage or cirrhosis in persons who screen positive.12

Among patients with abnormal results on liver function tests (measurement of aspartate aminotransferase, alanine aminotransferase, or bilirubin levels) who were tested for reasons other than HCV screening, finding the cause of the abnormality often includes testing for HCV infection and is considered case finding rather than screening; therefore, it is outside the scope of this recommendation.

Screening Intervals

Most adults need to be screened only once. Persons with continued risk for HCV infection (eg, PWID) should be screened periodically. There is limited information about the specific screening interval that should occur in persons who continue to be at risk for new HCV infection or how pregnancy changes the need for additional screening.

Screening Implementation

Important considerations for implementation of screening include (1) communicating to patients that screening is voluntary and undertaken only with the patient’s knowledge and understanding that HCV screening is planned; (2) informing patients about HCV infection, how it can (and cannot) be acquired, the meaning of positive and negative test results, and the benefits and harms of treatment; and (3) providing patients the opportunity to ask questions and to decline screening.

Some health care systems serving insured populations, some academic medical centers, and the Veterans Health Administration have achieved high rates of HCV screening and treatment. However, national HCV screening rates in community health centers and from the National Health Interview Study were 8.3% and 17.3%, respectively; 1 study of 4 safety-net primary care practices serving low-income and uninsured or underserved populations found that only 0.8% of persons born in 1945 through 1965 were screened over a 1-year period.13 Implementation of successful screening may require addressing various barriers to screening and treatment in diverse populations, such as the uninsured.

Treatment

The purpose of antiviral treatment regimens for HCV infection is to prevent long-term health complications of chronic HCV infection (eg, cirrhosis, liver failure, and hepatocellular carcinoma).

Currently, all oral direct-acting antiviral (DAA) regimens without interferon have been accepted as the standard treatment for chronic HCV infection. Antiviral therapy is not generally considered during pregnancy because of the lack of data on the safety of newer DAA regimens during pregnancy and breastfeeding.1415

Additional Tools and Resources

The Centers for Disease Control and Prevention provides strategies for implementing a testing program and additional risk factors at https://www.cdc.gov/hepatitis/hcv/guidelinesc.htmThis link goes offsite. Click to read the external link disclaimer.16

Other Related USPSTF Recommendations

The USPSTF has made recommendations on screening for hepatitis B virus infection in pregnant persons,17 screening for hepatitis B virus infection in adults,18 and screening for HIV infection.19

Update of Previous USPSTF Recommendations

Thisis recommendation incorporates new evidence and replaces the 2013 USPSTF recommendation, which recommended screening for HCV infection in persons at high risk for infection and 1-time screening in adults born between 1945 and 1965 (B recommendation).20 The new USPSTF recommendation expands the ages for screening to all adults from 18 to 79 years.

The treatment of HCV continues to evolve, resulting in greater benefits and fewer harms than when the USPSTF last considered the evidence. Direct-acting antiviral regimens are of shorter duration, with higher rates of sustained virologic response (SVR) and fewer serious harms than previous treatment regimens. Since 2013, the prevalence of HCV infection has increased in younger persons aged 20 to 39 years. There are limited epidemiologic data available on HCV incidence in adolescents younger than 18 years. The HCV infection prevalence rates in older adults born between 1945 and 1965 remain relatively high, and prevalence in the elderly will increase as this population ages. Clinical trials of DAA treatment included adults in their early 80s, which increases the evidence for the benefits of screening in older adults. In addition, many older adults could experience the benefits of screening. As a result, the USPSTF concluded that broadening the age for HCV screening beyond its previous recommendation will identify infected patients at earlier stages of disease who could greatly benefit from effective treatment before developing complications.

 

 


Rationale

Importance

Hepatitis C virus (HCV) is the most common chronic blood-borne pathogen in the US and a leading cause of complications from chronic liver disease.1 Hepatitis C virus infection is associated with more deaths than the top 60 other reportable infectious diseases combined, including HIV.2 The most important risk factor for HCV infection is past or current injection drug use.1 In the US, an estimated 4.1 million persons have past or current HCV infection (ie, they test positive for the anti-HCV antibody). Of these persons who test positive for the anti-HCV antibody, approximately 2.4 million have current infections based on testing with molecular assays for HCV RNA.13-5 The estimated prevalence of chronic HCV infection is approximately 1.0% (2013 to 2016).6 An estimated 44,700 new HCV infections occurred in the US in 2017.7 Cases of acute HCV infection have increased approximately 3.8-fold (2010 to 2017) over the last decade because of increasing injection drug use and improved surveillance.7 The most rapid increase in acute HCV incidence has been in young adults aged 20 to 39 years who inject drugs, with increases in both sexes but more pronounced in men.7 Rates increased especially in American Indian/Alaskan Native and non-Hispanic white populations.7

 

Magnitude of Net Benefit

The US Preventive Services Task Force (USPSTF) concludes with moderate certainty that screening for HCV infection in adults aged 18 to 79 years has substantial net benefit.

See the Table for more information on the USPSTF recommendation rationale and assessment. For more details on the methods the USPSTF uses to determine net benefit, see the USPSTF Procedure Manual.

 

 

 


Others

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