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In the Balance |

Testing for Hepatitis C Virus Infection Should Be Routine for Persons at Increased Risk for Infection FREE

Miriam J. Alter, PhD; Leonard B. Seeff, MD; Bruce R. Bacon, MD; David L. Thomas, MD; Michael O. Rigsby, MD; and Adrian M. Di Bisceglie, MD
[+] Article and Author Information

From National Center for Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia; National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland; American Association for the Study of Liver Diseases and The Infectious Diseases Society of America, Alexandria, Virginia; Veterans Health Administration, Department of Veterans Affairs, Washington, DC; and Hepatitis Council, American Liver Foundation, New York, New York.


Acknowledgments: The authors thank Jay H. Hoofnagle, MD, National Institutes of Health, Bethesda, Maryland, and John G. McHutchison, Duke University Medical Center, Durham, North Carolina, for their valuable contributions to this manuscript.

Potential Financial Conflicts of Interest: Consultancies: A.M. Di Bisceglie (Schering-Plough, Roche, Idenix, SciClone Pharmaceuticals, Chiron Corp., Vertex, 3M); Honoraria: D.L. Thomas (Roche, Schering-Plough), A.M. Di Bisceglie (Schering-Plough, Roche); Grants received: A.M. Di Bisceglie (Schering-Plough, Roche, Idenix, SciClone Pharmaceuticals); Other: D.L. Thomas (Chiron Corp., Roche).

Requests for Single Reprints: Miriam J. Alter, PhD, Division of Viral Hepatitis, Mailstop D66, Centers for Disease Control and Prevention, Atlanta, GA 30333.

Current Author Addresses: Dr. Alter: Division of Viral Hepatitis, Mailstop D66, Centers for Disease Control and Prevention, 1600 Clifton Road, Atlanta, GA 30333.

Dr. Seeff: Liver Disease Research Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, 31A Center Drive, Room 9A27, Bethesda, MD 20892.

Dr. Bacon: Saint Louis University School of Medicine, 3635 Vista Avenue, St. Louis, MO 63110.

Dr. Thomas: The Johns Hopkins Medical Institution, 1513 East Jefferson Street, Baltimore, MD 21231.

Dr. Rigsby: Department of Veterans Affairs, 950 Campbell Avenue, West Haven, CT 06516.

Dr. Di Bisceglie: Saint Louis University School of Medicine, 3635 Vista Avenue, St. Louis, MO 63110.


Ann Intern Med. 2004;141(9):715-717. doi:10.7326/0003-4819-141-9-200411020-00013
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Abstract

In the United States, chronic hepatitis C virus (HCV) infection affects an estimated 3 million persons, most younger than 50 years of age. It is one of the leading causes of chronic liver disease morbidity and mortality and the most common indication for liver transplantation. Effective treatment can eradicate the virus and eliminate or reduce liver inflammation and fibrosis, and counseling and immunization can modify or prevent the adverse effect of cofactors (for example, alcohol consumption or co-infections) on disease progression. However, controversy surrounds the need to routinely identify asymptomatic HCV-infected persons. Because no data currently demonstrate that treatment or other interventions will reduce future cases of HCV-related chronic disease and deaths, the U.S. Preventive Services Task Force found insufficient evidence to recommend for or against routine screening for HCV infection in adults at high risk. Chronic hepatitis C would require many years of follow-up to determine the incidence of complication after treatment of or other interventions in asymptomatic persons. It seems inappropriate to wait several decades to measure the impact of early identification of this viral infection when current data support a positive therapeutic effect that points to long-term benefits. In addition, treatment and other interventions must be provided before cirrhosis or liver failure occurs. Therefore, medical and public health professionals should continue the practice of screening persons for risk factors; offering testing to those at increased risk for HCV infection; and providing infected persons with appropriate counseling, medical evaluation, and treatment.

In 1998, the Centers for Disease Control and Prevention recommended that testing be routinely offered to persons most likely to be infected with hepatitis C virus (HCV) (Table) (1). This recommendation was part of a national strategy to identify HCV-infected persons and prevent the consequences of their infection, including transmission to others and further liver injury to themselves. Routine testing of the general population was not recommended.

Table Jump PlaceholderTable.  Recommendations for Hepatitis C Virus Testing

These testing recommendations were made only after sufficient progress in characterizing HCV-related disease burden, epidemiology, and natural history, as well as in developing diagnostics and therapeutics to fulfill the public health criteria for screening. These included 1) recognition that many persons in the United States (2.7 million) had chronic HCV infection, 2) identification of specific groups at increased risk for infection, 3) reliable tests for diagnosis and medical management, 4) improved antiviral therapies, 5) consensus guidelines on management and treatment of hepatitis C (34), 6) natural history data on the risk for HCV-related cirrhosis and other complications, and 7) identification of factors associated with increased morbidity or mortality (for example, alcohol consumption or co-infections) that could be modified or prevented through counseling and immunization.

Using different criteria, the U.S. Preventive Services Task Force, a nonfederal group of health experts that reviews published research and makes recommendations about preventive health care, published its statement on screening for HCV infection in adults in 2004 (5). Although the Task Force stated that the complications from chronic HCV infection present an enormous health burden that is expected to increase 2- to 4-fold over the next few decades, that screening can accurately detect chronic HCV infection, and that antiviral treatment can successfully eradicate viremia (6), it found insufficient evidence to recommend for or against routine screening for HCV infection in high-risk asymptomatic adults. The Task Force made its recommendation because it found no studies proving that screening for HCV infection leads to better long-term clinical outcomes, specifically fewer cases of HCV-related chronic disease and fewer deaths due to actions taken as a result of screening (for example, counseling and treatment). Also, it found insufficient evidence to determine the balance of benefits and harms.

We agree that currently no conclusive data from population-based studies indicate that antiviral therapy or modification of alcohol intake among HCV-infected persons decreases morbidity or mortality from cirrhosis or primary liver cancer. However, chronic hepatitis C is a protracted disease that requires prolonged follow-up (>20 to 30 years) to prove that treatment or other interventions increase life expectancy or quality. In the meantime, we have current data on which to base conclusions about such long-term benefits. Virus elimination (sustained virologic response) in 40% to 50% of treated persons infected with genotype 1 and 75% to 85% of those infected with genotypes 2 and 3, coupled with normalization of serum alanine aminotransferase (ALT) levels and improved liver histology, provides compelling evidence of a positive therapeutic effect (78). The U.S. Food and Drug Administration licensed treatment for chronic hepatitis C on the basis of these intermediate therapeutic effects and concluded that treatment benefits outweighed potential harms. Subsequent studies have demonstrated that these effects are maintained for at least 10 years, which further supports the expectation that current benefits will translate into long-term ones (9).

Independent of the benefits of treatment, there is compelling evidence for providing counseling, immunization, and other appropriate services to prevent or modify the combined adverse effects of cofactors and HCV infection on rapidity and severity of disease progression and on mortality. Hepatitis C virus infection and alcohol use are the leading causes of chronic liver disease–related morbidity and mortality in the United States (1011), and HCV-infected persons with cirrhosis are 2 to 16 times more likely to have a history of high alcohol intake than those with less severe liver disease (1213). Persons infected with HCV are also at increased risk for fulminant hepatitis if infected with hepatitis A virus and for more rapid progression of cirrhosis and liver failure if co-infected with HIV (1415). Finally, chronic hepatitis C is the most common indication for liver transplantation (16).

Thus, there are many good reasons for testing persons at increased risk. Persons with HCV infection identified through targeted testing can seek medical evaluation to determine the severity of their disease, to consider treatment, and to make lifestyle changes that could reduce the likelihood of disease progression. In addition, people who know their HCV infection status can avoid infecting others.

There are also potential harms associated with screening. The harms cited by the Task Force were related to false-positive test results (for example, anxiety), knowledge of HCV status (for example, discrimination), medical evaluation (for example, complications of liver biopsy), and treatment (for example, side effects) (56). Most of these potential harms can be prevented or substantially reduced. For example, there is no reason for a patient to receive a false-positive result on a screening test. All positive results on HCV screening tests should be confirmed with additional, more specific testing (12, 1718), which is routinely available to clinicians. This recommendation, which is consistent with testing practices for hepatitis B surface antigen and HIV antibody, minimizes unnecessary medical visits and psychological harm for persons with false-positive results on screening assays. In addition, it ensures that counseling, medical referral, and evaluation are targeted to patients confirmed as having been infected with HCV. Cost-efficient methods for routine confirmatory HCV testing have been developed (17).

As the Task Force indicated, severe complications of liver biopsy are rare, with an incidence of 0.3% (6). However, even rare adverse events can be minimized by performing liver biopsy only when the results will influence treatment recommendations (2). In addition, the side effects of treatment are usually self-limited and can be minimized by recommending treatment only for patients most likely to benefit, that is, those with an increased risk for cirrhosis (2, 4, 18). These patients are characterized by detectable HCV RNA, a liver biopsy specimen with portal or bridging fibrosis, and at least moderate inflammation and necrosis. Most also have persistently elevated ALT levels. In some patient populations, the risks and benefits of therapy are less clear and treatment decisions should be individualized according to severity of liver disease, potential for serious side effects, likelihood of treatment response, and presence of comorbid conditions (2, 4, 18).

The potential harm of learning that one is HCV-positive is more difficult to define. It could involve disclosure of test results, which might result in disrupted personal relationships and possible discriminatory action, such as loss of employment, insurance, and educational opportunities. To minimize possible adverse consequences, the Centers for Disease Control and Prevention recommends that testing be preceded by appropriate counseling (1), which allows the individual patient to make an informed decision about testing. Furthermore, when routine testing is limited to those most likely to be infected, a high proportion of persons with positive results can be identified by testing a small proportion of the population (19).

The Task Force did recommend that physicians test patients with signs or symptoms of liver disease for HCV infection. However, most persons with chronic hepatitis C are asymptomatic despite the presence of active disease. The most frequent symptom of chronic hepatitis is fatigue, which is typically mild and intermittent and is often difficult to attribute to liver disease. Symptoms do not reliably develop in chronic hepatitis until cirrhosis is present (20); at that point, it is too late for therapy to have a major impact on survival. Most patients with HCV infection are identified when they donate blood or when abnormal ALT levels are detected during a routine medical examination or evaluation for an unrelated problem. An abnormal ALT value is a laboratory abnormality, not a symptom or sign of liver disease. The Centers for Disease Control and Prevention and the National Institutes of Health's Consensus Development Conference Panel recommend testing persons with abnormal ALT levels for HCV infection; this is widely accepted as the standard of care (12, 4, 18).

We clearly need further research on the long-term effectiveness of antiviral therapy and counseling to reduce hepatitis C–related liver damage. There is also a need to expand approaches to managing persons with chronic hepatitis C in the general population, many of whom have confounding medical or other conditions (21). However, the sheer number of relatively young persons with chronic HCV infection who may develop complications as they age emphasizes the need to identify them as part of current clinical and public health prevention activities. It seems inappropriate to interrupt current HCV testing practices and wait several decades to prove beyond doubt that rates of HCV-related chronic disease will decrease with early identification. It is imperative that medical and public health professionals use the available evidence and the collective judgment of experts to continue the best practice of screening persons for risk factors; offering testing to those at increased risk; and providing infected persons with appropriate counseling, medical evaluation, and treatment.

References

Recommendations for prevention and control of hepatitis C virus (HCV) infection and HCV-related chronic disease. MMWR Morb Mortal Wkly Rep. 1998;47(RR-19):1-33. Available athttp://www.cdc.gov/mmwr/PDF/rr/rr4719.pdf.
 
Strader DB, Wright T, Thomas DL, Seeff LB.  Diagnosis, management, and treatment of hepatitis C. Hepatology. 2004; 39:1147-71. PubMed
CrossRef
 
.  National Institutes of Health Consensus Development Conference Panel statement: management of hepatitis C. Hepatology. 1997; 26:2S-10S. PubMed
 
National Institutes of Health Consensus Development Conference Statement: Management of hepatitis C: 2002—June 10–12, 2002. Hepatology. 2002;36:S3-20. [PMID: 12407572] Available athttp://www3.interscience.wiley.com/cgi-bin/fulltext/106597945/PDFSTART.
 
.  Screening for hepatitis C virus infection in adults: recommendation statement. Ann Intern Med. 2004; 140:462-4. PubMed
 
Chou R, Clark EC, Helfand M.  Screening for hepatitis C virus infection: a review of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med. 2004; 140:465-79. PubMed
 
Manns MP, McHutchison JG, Gordon SC, Rustgi VK, Shiffman M, Reindollar R, et al..  Peginterferon alfa-2b plus ribavirin compared with interferon alfa-2b plus ribavirin for initial treatment of chronic hepatitis C: a randomised trial. Lancet. 2001; 358:958-65. PubMed
 
Fried MW, Shiffman ML, Reddy KR, Smith C, Marinos G, Goncales FL Jr, et al..  Peginterferon alfa-2a plus ribavirin for chronic hepatitis C virus infection. N Engl J Med. 2002; 347:975-82. PubMed
 
Lau DT, Kleiner DE, Ghany MG, Park Y, Schmid P, Hoofnagle JH.  10-Year follow-up after interferon-alpha therapy for chronic hepatitis C. Hepatology. 1998; 28:1121-7. PubMed
 
Frieden TR, Ozick L, McCord C, Nainan OV, Workman S, Comer G, et al..  Chronic liver disease in central Harlem: the role of alcohol and viral hepatitis. Hepatology. 1999; 29:883-8. PubMed
 
Vong S, Bell BP.  Chronic liver disease mortality in the United States, 1990-1998. Hepatology. 2004; 39:476-83. PubMed
 
Corrao G, Arico S.  Independent and combined action of hepatitis C virus infection and alcohol consumption on the risk of symptomatic liver cirrhosis. Hepatology. 1998; 27:914-9. PubMed
 
Wiley TE, McCarthy M, Breidi L, McCarthy M, Layden TJ.  Impact of alcohol on the histological and clinical progression of hepatitis C infection. Hepatology. 1998; 28:805-9. PubMed
 
Vento S, Garofano T, Renzini C, Cainelli F, Casali F, Ghironzi G, et al..  Fulminant hepatitis associated with hepatitis A virus superinfection in patients with chronic hepatitis C. N Engl J Med. 1998; 338:286-90. PubMed
 
Thomas DL.  Hepatitis C and human immunodeficiency virus infection. Hepatology. 2002; 36:S201-9. PubMed
 
Roberts MS, Angus DC, Bryce CL, Valenta Z, Weissfeld L.  Survival after liver transplantation in the United States: a disease-specific analysis of the UNOS database. Liver Transpl. 2004; 10:886-97. PubMed
 
Guidelines for laboratory testing and result reporting of antibody to hepatitis C virus. MMWR Morb Mortal Wkly Rep. 2003;52(RR-3):1-15. Available athttp://www.cdc.gov/mmwr/PDF/rr/rr5203.pdf.
 
Veterans Health Administration.  Treatment recommendations for patients with chronic hepatitis C. Version 5.0. Federal Practitioner. 2003;20(Suppl 5):7-32. Available athttp://www.hepatitis.va.gov.
 
Gunn RA, Murray PJ, Brennan CH, Callahan DB, Alter MJ, Margolis HS.  Evaluation of screening criteria to identify persons with hepatitis C virus infection among sexually transmitted disease clinic clients: results from the San Diego Viral Hepatitis Integration Project. Sex Transm Dis. 2003; 30:340-4. PubMed
 
Seeff LB, Hollinger FB, Alter HJ, Wright EC, Cain CM, Buskell ZJ, et al..  Long-term mortality and morbidity of transfusion-associated non-A, non-B, and type C hepatitis: A National Heart, Lung, and Blood Institute collaborative study. Hepatology. 2001; 33:455-63. PubMed
 
Di Bisceglie AM, Hoofnagle JH.  Optimal therapy of hepatitis C. Hepatology. 2002; 36:S121-7. PubMed
 

Figures

Tables

Table Jump PlaceholderTable.  Recommendations for Hepatitis C Virus Testing

References

Recommendations for prevention and control of hepatitis C virus (HCV) infection and HCV-related chronic disease. MMWR Morb Mortal Wkly Rep. 1998;47(RR-19):1-33. Available athttp://www.cdc.gov/mmwr/PDF/rr/rr4719.pdf.
 
Strader DB, Wright T, Thomas DL, Seeff LB.  Diagnosis, management, and treatment of hepatitis C. Hepatology. 2004; 39:1147-71. PubMed
CrossRef
 
.  National Institutes of Health Consensus Development Conference Panel statement: management of hepatitis C. Hepatology. 1997; 26:2S-10S. PubMed
 
National Institutes of Health Consensus Development Conference Statement: Management of hepatitis C: 2002—June 10–12, 2002. Hepatology. 2002;36:S3-20. [PMID: 12407572] Available athttp://www3.interscience.wiley.com/cgi-bin/fulltext/106597945/PDFSTART.
 
.  Screening for hepatitis C virus infection in adults: recommendation statement. Ann Intern Med. 2004; 140:462-4. PubMed
 
Chou R, Clark EC, Helfand M.  Screening for hepatitis C virus infection: a review of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med. 2004; 140:465-79. PubMed
 
Manns MP, McHutchison JG, Gordon SC, Rustgi VK, Shiffman M, Reindollar R, et al..  Peginterferon alfa-2b plus ribavirin compared with interferon alfa-2b plus ribavirin for initial treatment of chronic hepatitis C: a randomised trial. Lancet. 2001; 358:958-65. PubMed
 
Fried MW, Shiffman ML, Reddy KR, Smith C, Marinos G, Goncales FL Jr, et al..  Peginterferon alfa-2a plus ribavirin for chronic hepatitis C virus infection. N Engl J Med. 2002; 347:975-82. PubMed
 
Lau DT, Kleiner DE, Ghany MG, Park Y, Schmid P, Hoofnagle JH.  10-Year follow-up after interferon-alpha therapy for chronic hepatitis C. Hepatology. 1998; 28:1121-7. PubMed
 
Frieden TR, Ozick L, McCord C, Nainan OV, Workman S, Comer G, et al..  Chronic liver disease in central Harlem: the role of alcohol and viral hepatitis. Hepatology. 1999; 29:883-8. PubMed
 
Vong S, Bell BP.  Chronic liver disease mortality in the United States, 1990-1998. Hepatology. 2004; 39:476-83. PubMed
 
Corrao G, Arico S.  Independent and combined action of hepatitis C virus infection and alcohol consumption on the risk of symptomatic liver cirrhosis. Hepatology. 1998; 27:914-9. PubMed
 
Wiley TE, McCarthy M, Breidi L, McCarthy M, Layden TJ.  Impact of alcohol on the histological and clinical progression of hepatitis C infection. Hepatology. 1998; 28:805-9. PubMed
 
Vento S, Garofano T, Renzini C, Cainelli F, Casali F, Ghironzi G, et al..  Fulminant hepatitis associated with hepatitis A virus superinfection in patients with chronic hepatitis C. N Engl J Med. 1998; 338:286-90. PubMed
 
Thomas DL.  Hepatitis C and human immunodeficiency virus infection. Hepatology. 2002; 36:S201-9. PubMed
 
Roberts MS, Angus DC, Bryce CL, Valenta Z, Weissfeld L.  Survival after liver transplantation in the United States: a disease-specific analysis of the UNOS database. Liver Transpl. 2004; 10:886-97. PubMed
 
Guidelines for laboratory testing and result reporting of antibody to hepatitis C virus. MMWR Morb Mortal Wkly Rep. 2003;52(RR-3):1-15. Available athttp://www.cdc.gov/mmwr/PDF/rr/rr5203.pdf.
 
Veterans Health Administration.  Treatment recommendations for patients with chronic hepatitis C. Version 5.0. Federal Practitioner. 2003;20(Suppl 5):7-32. Available athttp://www.hepatitis.va.gov.
 
Gunn RA, Murray PJ, Brennan CH, Callahan DB, Alter MJ, Margolis HS.  Evaluation of screening criteria to identify persons with hepatitis C virus infection among sexually transmitted disease clinic clients: results from the San Diego Viral Hepatitis Integration Project. Sex Transm Dis. 2003; 30:340-4. PubMed
 
Seeff LB, Hollinger FB, Alter HJ, Wright EC, Cain CM, Buskell ZJ, et al..  Long-term mortality and morbidity of transfusion-associated non-A, non-B, and type C hepatitis: A National Heart, Lung, and Blood Institute collaborative study. Hepatology. 2001; 33:455-63. PubMed
 
Di Bisceglie AM, Hoofnagle JH.  Optimal therapy of hepatitis C. Hepatology. 2002; 36:S121-7. PubMed
 

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Hepatitis C patients with psychiatric illness: the forgotten
Posted on November 4, 2004
Muhamad Aly Rifai
National Institute of Mental Health, National Institutes of Health, Bethesda, Maryland
Conflict of Interest: None Declared

The clinical management of individuals with co-morbid hepatitis C virus (HCV) chronic infection and psychiatric illness is a substantial public health problem. The prevalence rates of psychiatric illness (affective, anxiety and psychotic disorders) in patients with HCV infection are at least double the rates of psychiatric illness in the US population (1-3). Furthermore, patients with psychiatric illness have significantly higher HCV infection rates when compared with the US population [10-20% vs. 1-2 %] (3). Despite such association, routine screening for HCV has not been recommended for patients with psychiatric illness. These patients are at high-risk for contracting HCV by engaging in high- risk behaviors and may not be forthcoming about risk factors for HCV infection.

The use of interferon-based therapies (IFN) has been problematic in HCV patients with psychiatric illness. Neuropsychiatric side effects occurred in at least half of those treated in HCV clinical trials reporting sustained virologic response (SVR) rates of 54- 56% (3). Fearing reduced SVR rates and the precipitation or worsening of pre-existing psychiatric illness with IFN, these trials excluded patients with histories of psychiatric or substance use disorders. In contrast to HCV-treatment trials, other reports (4, 5) detailing the clinical experience with IFN use describe little success in engaging patients with HCV treatment, and poorer SVR rates (10-15 %). These reports cite psychiatric illness and substance use as the main factors for HCV treatment ineligibility in at least half of the HCV patients being evaluated (4, 5).

The practice of excluding patients with HCV and psychiatric illness from IFN treatment is stigmatizing and can result in substantial morbidity and mortality for a vulnerable population no less deserving of treatment than HCV patients without psychiatric illness. The HCV-population with psychiatric illness is quite unique, as psychotropics (antidepressants, antipsychotics, mood stabilizers) are metabolized by the liver and are associated with significant hepatotoxicity. The combination of HCV-induced liver disease and psychotropics use (not to mention alcohol use) may hasten the progression to cirrhosis. Patients with HCV and psychiatric illness may also be less likely to receive a liver- transplant due to the perceived difficulties they might have in complying with the rigorous-post transplant regimen. In this context, the argument about the lack of data supporting the utility of IFN treatment in reducing morbidity and mortality from cirrhosis and primary liver cancer may not be applicable to the HCV population with psychiatric illness. In conclusion, there is a pressing need to develop recommendations on screening and treatment of HCV in patients with psychiatric illness.

References:

1. Yovtcheva SP, Rifai MA, Moles JK, Van Der Linden BJ. Psychiatric Comorbidity Among Hepatitis C-Positive Patients. Psychosomatics. 2001;42(5):411-415.

2. el-Serag HB, Kunik M, Richardson P, Rabeneck L. Psychiatric disorders among veterans with hepatitis C infection. Gastroenterology. 2002;123(2):476-82.

3. Rosenberg SD, Swanson JW, Wolford GL, et al. Blood-Borne Infections and Persons With Mental Illness: The Five-Site Health and Risk Study of Blood-Borne Infections Among Persons With Severe Mental Illness. Psychiatric Services. 2003;54(6):827-835.

4. Cawthorne CH, Rudat KR, Burton MS, et al. Limited success of HCV antiviral therapy in United States veterans. The American Journal of Gastroenterology. 2002;97(1):149-155.

5. Falck-Ytter Y, Kale H, Mullen KD, Sarbah SA, Sorescu L, McCullough AJ. Surprisingly Small Effect of Antiviral Treatment in Patients with Hepatitis C. Ann Intern Med. 2002;136(4):288-292.

Lack of cost-effectiveness studies in hepatitis C screening programs
Posted on November 16, 2004
Pedro Schestatsky
Consultant of Brazilian Ministry of Health; Post-grad. program in Med. Scien - UFRGS/Brazil
Conflict of Interest: None Declared

We agree with Alter MJ et al.(1) concerning their critical appraisal of literature, which resulted on lacking of evidence on clinical course of hepatitis C and the impact of treatment in the long run. As the authors declared, the two leading causes of liver diseases worldwide are hepatitis C and alcohol, for what educational programs and restriction of alcoholic beverages consumption might have impact in preventing liver diseases. A cost-effectiveness study (2) showed that the most beneficial effect of treatment, in terms of QALY, was the recovery of the quality of live lost with the HCV-positive status. It is our opinion that a non-selected screening strategy could be harmful instead of providing benefit. Even knowing the HCV-status might prevent from fulminant hepatitis A, this strategy has not been tested, as well as the theoretical risk reduction of transmission after testing. In our opinion, cost-effectiveness analysis is lacking in order to balance the evidence-based conclusions in this field. It seems particularly relevant when these are public health actions, which, in their turn, involve millions of dollars expended by the public health systems.

Conflict of Interest:

None declared

Re: Lack of cost-effectiveness studies in hepatitis C screening programs
Posted on December 22, 2004
MOSHE SCHMIDT
VA,,NY - HARBOR HEALTH CARE SYSTEM
Conflict of Interest: None Declared

TESTING FOR HEPATITIS C VIRUS INFECTION OR TREATING IT

THE AUTHORS,ALTER AND ASSOCIATES DISCUSS THE ISSUES OF TESTING AND OF TREATING WHICH NEED TO BE CLEARLY SEPARATED.I WOULD HAVE LIKED TO SEE THE RISK/BENEFIT DATA FOR TESTING IN ORDER TO PREVENT TRANSMISSION OF THE VIRUS TO OTHERS. AS THE AUTHORS AGREE ABOUT THE LACK OF CONCLUSIVE DATA TO SUPPORT THE DELIVERY OF ANTIVIRAL THERAPY WITH IT'S PROVEN ASSOCIATED RISKS AND GARGANTUAN BURDEN FOR SOCIETY AS A WHOLE,THEIR CONCLUSIONS THAT "IT IS IMPERATIVE"..."OFFERING TESTING...AND TREATMENT" IS, I BELIEVE A CONTRADICTION. WOULD THE AUTHORS AGREE THAT ALL ANTIVIRAL TREATMENT OF THIS DISORDER SHOULD BE CATEGORIZED AS A VALUABLE EXPERIMENT AND ALSO TREATED AS SUCH?

Conflict of Interest:

None declared

Testing and managing HCV-infected health care workers
Posted on January 13, 2005
Nicola Magnavita
Institute of Occupational Medicine, Catholic University School of Medicine, Rome, Italy
Conflict of Interest: None Declared

I'm a physician charged of medical surveillance of hospital workers. I strongly agree with Alter's et al. and Rich's et al. warnings (1,2) against interruption of HCV testing practices of health care workers (HCWs). Testing HCWs for HCV proved to be cost-effective before performing exposure-prone procedures (EPPs), after needlestick or mucosal exposure, and if abnormal ALT levels are detected during a routine medical examination. Periodical testing might also be useful in detecting unapparent infections, specially in HCWs operating on high-risk populations, such as infectious disease departments, and prisons. To date, most European countries have no national policy for HCV infected HCWs, and existing guidelines are advisory in nature, and poorly enforced. A panel of European and American experts recently failed to reach a consensus statement as to how to manage HCV infected HCWs who perform EPPs, and concluded that screening for and restricting HCV infected HCWs is not justified, based on current published data (3). The worst option, however, is the "zero" policy, overlooking the problem. I recently witnessed the case of a university-teacher, who had been working as surgeon since 1969 in a university hospital. In 1972 he developed hepatitis B virus infection that subsequently healed. In 1974 he developed "nonA-nonB hepatitis", later diagnosed as chronic HCV-infection. In 1975 he was diagnosed at King's College Hospital in London as having hypersensitivity (toxic) hepatitis from halogenated anesthetics. The combined adverse effect of toxic factor and HCV infection was alarming. The surgeon signaled his health status to the university hospital management, but no appropriate preventive measure was taken. The surgeon tried to by-pass gas hazard, by using neuroleptoanalgesia; anesthetic gas, however, were used by neighboring surgeons. In subsequent years, when exposed to anesthetic gas, he showed recurrent increases of ALT. In 1998 he completely ceased surgical activity and suited the hospital. The court rejected his claim, on the consideration that the observed enzymatic changes could not be attributed without doubt to anesthetic gas hazard, owing the confounding effect of HCV chronic liver infection. No penal charge of university management was decided, notwithstanding the proved absence of preventive measures, both at individual and collective level. Given the fact that the surgeon remained HCV-RNA positive for 25 years of career, the risk of having transmitted HCV in at least one of the procedures performed, can be evaluated to be almost 88% (4). It is imperative that public health services effectively screen and manage infectious HCWs.

Nicola Magnavita, M.D. Institute of Occupational Medicine, Catholic University School of Medicine, Largo Gemelli 8, 00168 Rome, Italy.

References 1.Alter MJ, Seeff LB, Bacon BR, Thomas DL, Rigsby MO, Di Bisceglie AM. Testing for hepatitis C virus infection should be routine for persons at increased risk for infection. Ann Intern Med 2004; 141: 715-718 2.Rich JD, Taylor LE, Allen SA. Screening for hepatitis C virus infection in adults. Ann Intern Med 2004; 141: 575-576 3.Gunson RN, Shouval D, Roggendorf M, et al. Hepatitis B virus (HBV) and hepatitis C virus (HCV) infections in health care workers (HCWs): guidelines for prevention of transmission of HBV and HCV from HCW to patient. J Clin Virol 2003; 27: 213-230. 4.Ross RS, Viazov S, Roggendorf M. Risk of hepatitis C transmission from infected medical staff to patients. Arch Intern Med 2000; 160: 2313-2316

Conflict of Interest:

None declared

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