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Hepatitis C Virus Testing of Persons Born During 1945–1965

Richard B. Lynn, MD
[+] Article and Author Information

From American College of Physicians, Philadelphia, Pennsylvania.

Potential Conflicts of Interest: Employment: Pfizer.


Ann Intern Med. 2013;158(9):704. doi:10.7326/0003-4819-158-9-201305070-00014
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Letters

May 7, 2013
Ephraim Back, MD, MPH
From Ellis Hospital, Schenectady, New York.
AIM. 2013;158(9):704-705  doi:10.7326/0003-4819-158-9-201305070-00015



May 7, 2013
Bryce D. Smith, PhD; Deborah Holtzman, PhD; John W. Ward, MD
From Centers for Disease Control and Prevention, Atlanta, Georgia.
AIM. 2013;158(9):705  doi:10.7326/0003-4819-158-9-201305070-00016



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Hepatitis C Virus Testing of Persons Born During 1945–1965
Posted on June 3, 2013
Brian R. Edlin, MD, FACP, FIDSA
National Development and Research Institutes, Center for the Study of Hepatitis C, Weill Cornell Medical College
Conflict of Interest: None Declared

Richard Lynn [1] points out, correctly, that screening all asymptomatic adults born during 1945-65 for hepatitis C will result in testing many people at low risk. But the strategy Dr. Lynn proposes would rely on a risk factor assessment that is invasive and unlikely to be carried out completely. Dr. Lynn may be right that he can accurately recall his lifetime number of sex partners. But it would be foolish to base national hepatitis C screening policy on the expectation that all physicians will ask for this information and all patients will accurately recall and report it, especially when the number is larger than they might want recorded in their electronic health record. Injection drug use, a highly stigmatized behavior that patients are reluctant to disclose to healthcare providers under any circumstances, is something they may not remember or consider relevant if it happened only once many years in the past. And recall of blood transfusions received decades previously is sketchy at best.

 

The fact is that it is simply not possible to separate the population into discrete high- and low-risk groups in order to avoid testing those at low risk. People exist on a continuum of risk  [2]. The list of groups with an increased prevalence of hepatitis C virus (HCV) infection is long (Table [2-7]). Testing people who have none of these characteristics will certainly have a very low yield. But most adults fall into one or another of the groups listed in the Table. Even the controversial 2004 United States Preventive Services Task Force (USPSTF) guideline, which recommended against testing people not at increased risk, does not apply to people in these groups, who are known to be at increased risk.

 

Trying to distinguish those who are at risk from the rest of us, who presumably are not, often turns out not to be effective public health strategy. We learned this when targeting high-risk groups for hepatitis B vaccination proved ineffective and was replaced with universal vaccination, and again when universal HIV screening proved necessary, as the USPSTF now agrees. If we continue to select people for HCV testing whom we perceive to be “at risk,” we will save money in the short term — although not very much — but will miss many infections and many opportunities to reduce liver-related morbidity and mortality. As the death toll from hepatitis C rises year by year, we can, and must, do better.

 

References

1.     Lynn RB. Hepatitis C virus testing of persons born during 1945-1965. Ann Intern Med 2013;158(9):704. PMID: 23648952.

2.     Edlin BR. Perspective: test and treat this silent killer. Nature 2011;474: S18-9.

3.     Armstrong GL, Wasley A, Simard EP, McQuillan GM, Kuhnert WL, Alter MJ. The prevalence of hepatitis C virus infection in the United States, 1999 through 2002. Ann Intern Med 2006;144:705-714.

4.     Louie KS, St Laurent S, Forssen UM, Mundy LM, Pimenta JM. The high comorbidity burden of the hepatitis C virus infected population in the United States. BMC Infect Dis 2012;12:86. PMID: 22494445. PMCID: PMC3342214

5.     Stepanova M, Kanwal F, El-Serag HB, Younossi ZM. Insurance status and treatment candidacy of hepatitis C patients: analysis of population-based data from the United States. Hepatology 2011;53(3):737-45. PMID: 21319199

6.     Edlin BR. Hepatitis C screening: getting it right. Hepatology 2013;57(4):1644-50.

7.     Edlin BR. Five million Americans infected with the hepatitis C virus: a corrected estimate. Hepatology 2005;42(4 Suppl 1):213A.

 

Table. Groups with an increased prevalence of infection with the hepatitis C virus (HCV)*

1.     Persons with a history of injection drug use

2.     Persons with a history of noninjected illicit substance use

3.     Persons with a history of heavy alcohol consumption

4.     Persons with mental health conditions

5.     Hemodialysis patients

6.     Persons who received a blood transfusion before 1992

7.     Persons with diabetes, hypertension, or other medical illnesses

8.     Persons lacking health insurance

9.     Persons without a college degree, especially those with < 12 years of education

10.  Persons living below 2 times the Federal poverty threshold, especially those living in poverty

11.  Persons who are homeless or incarcerated or have a history of homelessness or incarceration

12.  Persons with ≥ 10 lifetime sexual partners, especially those with ≥ 20 lifetime sexual partners

13.  Persons who had sex before they were 18

14.  Persons who have received unsafe injections in medical settings

15.  Persons who have received unsafe tattoos or body piercings

16.  Persons born in a high-prevalence country

17.  Persons born between 1945 and 1965

18.  African Americans

19.  Men

*Sources: (refs. 2-7)

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