The U.S. CDC (Centers for Disease Control and Prevention) has issued a strong recommendation that, even without known risk factors, all Americans born between 1945 and 1965 should have a one-time screening for the hepatitis C virus (HCV). This could be of special importance for persons in that age range, currently 47 to 67 years, with chronic pain conditions who may have received transfusions, injections, acupuncture, or other invasive medical procedures in the past, but were never specifically tested for HCV.
The recommendations, published early online in the Annals of Internal Medicine, also stress that all persons identified as infected with HCV should receive a brief alcohol screening and intervention and be referred to appropriate care and treatment services for HCV and related conditions [Smith et al. 2012]. Nearly 4 million persons in the United States are infected with HCV, a virus that can cause inflammation and permanent liver damage.
The infection is most prevalent among people born from 1945 through 1965, and up to 75% of those with HCV are unaware that they are infected, according to the CDC. This is a menacing problem, since HCV progresses slowly and the risk of serious complications increases as time passes.
The panel of 35 experts developing the recommendations sought to identify testing strategies that would increase the proportion of HCV-infected persons who are aware of their status. In particular, they assessed whether a testing strategy based on year of birth could help to identify persons living with HCV infection who have not been identified by prior risk-based testing.
They conducted a systematic review of evidence published between 1995 and February 2012 to assess the prevalence of HCV and clinical outcomes. The research suggested that the proportion of people born between 1945 and 1965 with HCV antibody was higher than that of the general population. Among that cohort, the recommendation authors also found strong evidence that achieving sustained virologic response (SVR) via appropriate treatment for HCV was associated with a reduced risk for death and liver cancer.
In persons identified as HCV-positive, the CDC further recommends a brief alcohol screening and intervention, since alcohol use has been shown to accelerate the progression of liver disease. This recommendation was based on a systematic review of 22 randomized, controlled trials published since 2010 to determine the effects of a brief alcohol intervention versus no intervention on reduction of alcohol use.
The research showed that patients who had a brief alcohol-reduction intervention decreased their weekly consumption significantly compared with those who had no intervention. Screening tools shown to be effective in eliciting history of alcohol use from patients include the Alcohol Use Disorders Identification Test available from the National Institute on Alcohol Abuse and Alcoholism [here], as well as guidance and intervention tools from the World Health Organization [here].
Previously, the CDC recommended HCV antibody screening only in persons with health or lifestyle indicators suggesting potential infection. However, low case identification in the past may have resulted from the difficulty of implementing risk-based screening given the limited time of primary care visits and unease in discussing behavioral risks with patients. Furthermore, accuracy of patient recall of risk behaviors, as well as past medical procedures, decreases over time.
Although not specifically addressed in the article, patients between 47 and 67 years of age being treated for chronic pain conditions should be considered for HCV screening, and especially those who have had invasive procedures of one type of another. The article also does not discuss costs, or public or private insurance plan coverage for the HCV screening test.
REFERENCE: Smith BD, Morgan R, Beckett GA, et al. Hepatitis C Virus Testing of Persons Born During 1945 to 1965: Recommendations From the Centers for Disease Control and Prevention. Ann Int Med. 2012(Aug 17); online ahead of print [available here].
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