USPSTF Recommends Universal Screening for Hepatitis C

SUMMARY:

USPSTF has reviewed available evidence and has updated its hepatitis C screening guidance. HCV is the most common chronic blood-borne pathogen in the US with potential for significant morbidity and mortality if left untreated. The prevalence of chronic HCV infection in the US is approximately 1.0% (2013 to 2016), with 44,700 new HCV infections in 2017. There has been an increase in acute infections over the last decade primarily due to increased injection drug use and better surveillance.

The USPSTF recommends screening for HCV infection in adults aged 18 to 79 years
Population: All asymptomatic adults aged 18 to 79 years without known liver disease
B level recommendation
- Offer or provide this service
- There is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial

The USPSTF concludes with moderate certainty that screening for HCV infection in adults aged 18 to 79 years has substantial net benefit

Risk Assessment

Screen all adults ages 18 to 79 years
Risk factors to consider
- Injection drug use: Consider screening adolescents <18 years or >79 years
  - Young adults (ages 18 to 30): Approximately 30% are infected
  - Older adults: 70% to 90% are infected
- Pregnancy
  - Screen pregnant adults

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 Test

Anti-HCV antibody testing followed by polymerase chain reaction testing for HCV RNA
- HCV infection can be detected by anti-HCV screening tests (enzyme immunoassay) 4 to 10 weeks after infection
- Delayed seroconversion may occur in immunocompromised individuals (e.g., those with HIV infection)

Screening Intervals

“Most adults need to be screened only once”
- Consider more frequent screening for individuals with ongoing risk (e.g., ongoing injection drug use)
- Data is limited to determine optimal screening interval for those at continued risk or whether pregnancy impacts need for additional screening

KEY POINTS:

Hepatitis C Overview

Acute Hepatitis C occurs within the first 6 months after exposure to HCV
Many individuals will remain asymptomatic
15% of patients will spontaneously clear the virus within 6 months
Signs and symptoms of acute HCV infection
- Fever | Fatigue | Dark urine | Clay-colored stool | Abdominal pain | Loss of appetite | Nausea and vomiting | Joint pain | Jaundice
- Most individuals with newly acquired HCV infection will be asymptomatic | 20 to 30% will exhibit symptoms
- Symptoms will usually appear within 2 to 12 weeks (range: 2–26 weeks) 
Signs and of chronic HCV infection
- Most people are asymptomatic or have non-specific symptoms (e.g., chronic fatigue and depression)
- Many eventually develop chronic liver disease, which can range from mild to severe, including cirrhosis and liver cancer
- Chronic HCV infection is typically not recognized until asymptomatic people are identified as HCV-positive when screened for blood donation or liver function tests return an abnormal result (e.g., elevated ALT), often during routine evaluation

Hepatitis C Treatment

Acute

The same regimens recommended for chronic HCV infections are recommended for acute infection

Chronic

Current antiviral therapies can result in sustained virologic response (SVR; absence of detectable virus 12 weeks after completion of treatment)
- SVR is indicative of a cure of HCV infection
- Over 90% of HCV infected persons can be cured of HCV infection regardless of HCV genotype with 8-12 weeks of oral therapy
- CDC provides a link to currently approved FDA therapies to treat hepatitis C (see ‘Learn More – Primary Sources’ below)

Other Considerations

Advise abstinence from alcohol and acetaminophen during acute infection
Evaluate for hepatitis B and HIV infection
Vaccinate against Hepatitis A and Hepatitis B
Evaluation for advanced hepatic fibrosis with
- Elastography or liver imaging (US or CT Scan)
- FIB-4 Score
- FIB-4 Calculator
- Lab tests: ALT | AST | Albumin | Bilirubin | INR | CBC
Provide education on how to prevent HCV transmission to others

Other Professional Recommendations

AASLD/IDSA
- One-time, routine, opt out HCV testing is recommended for all individuals aged 18 years and older
- One-time HCV testing should be performed for all persons less than 18 years old with behaviors, exposures, or conditions or circumstances associated with an increased risk of HCV infection
- Periodic repeat HCV testing should be offered to all persons with behaviors, exposures, or conditions or circumstances associated with an increased risk of HCV exposure
- Annual HCV testing is recommended for all persons who inject drugs and for HIV-infected men who have unprotected sex with men
- As part of prenatal care, all pregnant women should be tested for HCV infection, ideally at the initial visit
CDC
- All adults 18 years and older (except in settings where the prevalence is <0.1%)
- All pregnant persons should be screened for HCV during each pregnancy (except in settings where the prevalence of HCV infection is < 0.1%)
- All persons with risk factors (eg., persons with HIV, prior recipients of blood transfusions, persons who ever injected drugs and shared needles, and persons who are born to an HCV-infected mother) should be tested for HCV, with periodic testing while risk factors persist