CDC Expands HCV Testing, Refers HCW Issue to SHEA
Targeting undiagnosed infections
Conceding that the effectiveness of risk-based hepatitis C virus testing has plateaued, public health officials are rolling the dashboard dice to capture the grand-daddy of all birth cohorts: Baby Boomers.
The Centers for Disease Control and Prevention recommends that millions of Americans born from 1945 through 1965 get a one-time test for HCV.
Though many people may be completely unaware they are infected for years — they don't call it the "silent epidemic" for nothing — by the time they become symptomatic they may need to get in line for a liver transplant. Some 15,000 Americans, most of them baby boomers, die each year from HCV-related illness, such as cirrhosis and liver cancer. Deaths have been increasing steadily for more than a decade and are projected to grow significantly in coming years. The CDC estimates that HCV testing of baby boomers could identify more than 800,000 additional people with the virus.
With newly available therapies that can cure up to 75% of infections, expanded testing — along with linkage to appropriate care and treatment — could save a lot of livers and more than 120,000 actual lives, the CDC estimates. Indeed, with the development of protease inhibitors that can lower HCV viral counts as well as new antiviral drugs, there are more treatment options to offer the HCV infected.
The CDC's previous HCV recommendations called for testing only individuals with certain risk factors (i.e. blood transfusion prior to screening improvements in 1992, IV drug use). According to the CDC, baby boomers are five times more likely than other adults to be infected with HCV. Or put another way, more than 75% of the adults with HCV are in the famous birth cohort. In any case, there should be a lot more of them out there with HCV than presently detected, in part, because HCV is such a transmissible virus.
"Hepatitis C is actually a very infective virus — at least 10 times more so than HIV," says Bryce Smith, PhD, lead health scientist in the CDC Division of Viral Hepatitis. "HCV can live outside the body for as long as seven days, as we have seen with some of these outbreaks. One of the reasons that we recommend that anyone who has been on chronic hemodialysis be tested for HCV is just because there is a reasonable likelihood that they have been exposed to someone else's blood."
Somewhat surprisingly, the virus is not efficiently transmitted via sexual contact.
"The data is equivocal on sexual transmission, but we do know that sexual transmission does sometimes happen," he says. "The data kind of go back and forth on this particular point and right now we don't have a specific recommendation related to using condoms or using barrier methods. For example, we don't recommend that for long-term couples or 'sero-discordant' couples, where there is one person with [HCV] and one person without."
Is the CDC recommending that hospitals and health care providers routinely offer HCV tests to all their patients that fall within this age range?
"Yes," Smith says, though adding the caveat "local laws tend to [dictate] exactly how things like that can happen in terms of getting consent from the patient or whether it can be considered part of their routine blood work. Local laws will guide that, but it is definitely our recommendation that anyone born within 1945 through 1965 should be tested for HCV. Just one time."
Well, possibly two. A patient whose initial HCV antibody test is reactive is considered to either have current HCV infection or have had an HCV infection in the past that has subsequently resolved. To identify people with active HCV infection, those who test anti-HCV positive should be subsequently tested with a nucleic acid test (NAT).
"In essence it is kind of a two staged series," Smith says. "The first test is an antibody test. It tells you whether or not there is [HCV] antibody in the bloodstream, and again it is a very common and relatively inexpensive test. That will tell whether or not the patient has ever been infected with hepatitis C. We estimate that about 75% of people who have ever been infected go on to be chronically infected. [If they are positive], a second test has to be done to look for the presence of the virus itself in the bloodstream."
If so, the patient needs to get a full medical evaluation that would include an identification of the specific HCV genotype, measurement of their viral load and the best options for treatment. The NAT test could be done in a hospital, or the patient could be referred to their primary care physician or other "medical home" for the follow-up testing, he says.
As always, the question arises of who will pay for the testing. "Everyone has different types of insurance, but by and large it is our understanding that this [antibody] test is considered to be pretty routine," Smith says. "It is available just about everywhere. It is a test that generally speaking is covered by most insurance [programs]. We don't expect that to be a significant problem. We have looked really closely at the costs of this strategy and found that it is actually quite cost effective. It really is very similar to other routine preventive services like colorectal and cervical cancer screening or breast cancer screening.
Asked if health care workers within the targeted age range are also recommended for HCV testing, Smith says, "We are not making any distinction. I would say anyone who was born from 1945 to 1965 — who is a baby boomer — should be tested for hepatitis C. That is really regardless of their profession."
Of course the identification of HCV-positive health care workers raises the thorny issues of provider-to patient transmission, work restrictions and informing patients — much as it did when the CDC finally went to a universal HIV test recommendation in 2006. The CDC referred inquiries on the issue to the 2010 guidelines by the Society for Healthcare Epidemiology of America (SHEA).1 Those guidelines are quite specific in recommending recurrent testing for HCV viral counts and applying work restrictions to workers who perform so called exposure-prone invasive procedures. The precautions to be taken range from double-gloving to an outright restriction on performing certain procedures if the worker has a high viral load — defined as equal to or greater than 104 genome equivalents per milliliter of blood for HCV.
However, in what some say was an undermining omission, the guideline did not address routine testing of surgeons and other OR personnel — except to say that testing should not be mandatory and that health care workers performing invasive, exposure-prone procedures are "ethically obligated" to know their status. The European Consortium could not reach consensus on HCV-infected providers. The United Kingdom guideline states that HCV-infected providers with circulating RNA should not conduct exposure-prone procedures.
- Henderson DK, Dembry L, Fishman NO, et al. SHEA guideline for management of health care workers who are infected with hepatitis B virus, hepatitis C virus, and/or human immunodeficiency virus. Infect Control Hosp Epidemiol 2010; 31:203-232.