UPDATE: The Centers for Disease Control and Prevention (CDC) has updated their hepatitis C testing guidelines to include the recommendation of one-time testing of all people born during the 1945-1965 time period, regardless of their risk factors for hepatitis C. The addition of routine screening of this target population to the recommendations was the result of findings from studies (see below) that "baby boomers" had a disproportionally higher prevalence of hepatitis C infection than other age groups. The CDC is advising that those who test positive receive screening for alcohol use and intervention as needed, followed by referral to appropriate care for the hepatitis C infection and related conditions.
Original article published April 19, 2012:
More Americans today die from hepatitis C than from HIV, according to a new study by the Centers for Disease Control and Prevention (CDC) in the Annals of Internal Medicine. The rise in deaths affects people born between 1945 and 1964, most of whom are unaware that they have even been infected by this slowly progressing disease. A second study in the same journal demonstrates that routine age-based screening followed by treatment can be a cost-effective method to prevent serious liver disease and premature death.
Examining data from 1999-2007, research has demonstrated a significant rise in deaths from hepatitis C that has surpassed those from HIV/AIDS. While HIV-related deaths have declined to 12,734 recorded, deaths from hepatitis C virus (HCV) rose significantly to 15,106 and are anticipated to reach 35,000 by 2030. Over 3.2 million Americans are living with chronic HCV infection, which can cause long-term liver damage; without treatment, it is estimated that as many as half will develop cirrhosis and/or hepatocellular carcinoma, a type of liver cancer, both of which can be fatal. Two-thirds of this population are between the ages of 47 and 67 and are now entering a period of risk for these late complications of chronic hepatitis C infection.
HCV-related disease and death is preventable if detected and treated. The current CDC recommendation is risk-based screening for persons who experimented with intravenous (IV) drugs, underwent hemodialysis, or received blood transfusions before routine blood screening was introduced. This approach has achieved only limited success in raising awareness as many people at risk may not see doctors and physicians don't ask routine questions about these risk factors. Additionally, there are reports of hepatitis C in individuals for whom no risk factors can be identified.
Approximately 50-75% of people at risk and who may have contracted the virus 40 years ago are unaware of their condition as it is a slow-progressing disease and can be relatively asymptomatic for decades. Those at risk see no reason to seek testing as long-ago behavior is not easily linked to current liver problems, and doctors are reluctant to ask sensitive questions about 40-year old behavior.
The CDC undertook a study to determine whether routine age-based screening would raise the rate of cure and be cost-effective. Using data from the National Health and Nutrition Examination survey (NHANES), the U.S. Census and other sources, researchers conducted a simulated study that compared three different screening scenarios: no screening, risk-based screening, and age-based screening for all people born between 1945 and 1964. For the last two groups, they also considered the cost of treatment with two or (for the age-based screening group) three drugs. The research also analyzed cost-effectiveness of the scenarios and found the last scenario (age-based screening with use of three-drug treatment) to be most cost effective.
The study concluded that expanding the strategy to include routine screening of all individuals born between 1945 and 1964, regardless of risk factors, followed by standard therapy would reduce deaths by over 82,000 and that using newer three-drug treatments would save over 121,000 lives. Fully implemented, routine age-based screening would identify 85.9% of all undiagnosed cases compared with 21% in risk-based screening and would be cost-effective. Newer drug regimens that improve treatment effectiveness will also improve cost-effectiveness ratios. The CDC is currently reviewing its HCV prevention and control guidelines to consider inclusion of these recommendations.
Before 2000, chronic HCV was curable in only 10% of cases. Now, treatments for HCV can cure around 60-70% of those detected before late complications occur. Treatments are evolving at a pace that could reach nearly 90% cure rates with drugs that are currently being researched. This would increase the opportunity to intervene early and prevent HCV-associated deaths. Rising success rates should increase interest in screening by both physicians and members of the baby-boomer generation.
Despite the improved cure rates from treatment and the hope of even higher cure rates in the near future, there has been limited attention paid to recognizing the majority of infected people who do not know they have this potentially curable infection. If the disease is not detected until late complications such as cirrhosis and hepatocellular carcinoma develop, treatment is usually not an option at present. The Institute of Medicine has called for an intensified and coordinated national effort to detect those chronically infected, treat persons discovered with HCV-induced disease, and to prevent new cases of infection.
"A national 'find-and-treat' policy is needed to achieve maximum screening of HCV carriers and to provide a significant number of them with new-generation therapies,” wrote National Institutes of Health doctors Harvey Alter and T. Jake Liang in an Annals of Internal Medicine editorial. "The goal to prevent fibrosis progression and cancer evolution in patients with HCV infection is now achievable if our collective (political) will can evolve as rapidly as our pharmacologic skill."
To date, no vaccine exists for hepatitis C, but efforts to develop one are on-going. The National Institutes of Health has provided private-sector funding to develop a gene-based vaccine that stimulates an immune response to prevent HCV from taking hold in those at risk of infection.
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NOTE: This article is based on research that utilizes the sources cited here as well as the collective experience of the Lab Tests Online Editorial Review Board. This article is periodically reviewed by the Editorial Board and may be updated as a result of the review. Any new sources cited will be added to the list and distinguished from the original sources used. To access online sources, copy and paste the URL into your browser.
Ly K, et al. The Increasing Burden of Mortality From Viral Hepatitis in the United States Between 1999 and 2007. Ann Intern Med, February 21, 2012 vol. 156 no. 4 271-278. Available online http://www.annals.org/content/156/4/271.full through http://www.annals.org. Accessed April 8, 2012.
Rein D, et al. The Cost-Effectiveness of Birth-Cohort Screening for Hepatitis C Antibody in U.S. Primary Care Settings. Ann Intern Med, February 21, 2012, vol. 156 no. 4, 263-269. Available online at http://www.annals.org/content/156/4/263-270 through http://www.annals.org. Accessed April 8, 2012.
Alter H.J, Liang T.J, Hepatitis C. The End of the Beginning and Possibly the Beginning of the End. Ann Intern Med, February 21, 2012, vol 156 no. 4, 317-318. Available online at http://www.annals.org/content/156/4/317 through http://www.annals.org. Accessed April 8, 2012.
Makiko Kitamura (Mar 14, 2012). Former Merck Unit Works on First Vaccine for Hepatitis C. Bloomberg. Available online at http://www.bloomberg.com/news/2012-03-14/former-merck-unit-works-on-first-vaccine-for-hepatitis-c.html through http://www.bloomberg.com. Accessed April 8, 2012.
Centers for Disease Control and Prevention. Recommendations for the Identification of Chronic Hepatitis C Virus Infection Among Persons Born During 1945–1965. Prepared by Smith, Bryce D. et al. MMWR. August 17, 2012. Available online at http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6104a1.htm?s_cid=rr6104a1_w through http://www.cdc.gov. Accessed August 2012.