Should DOMs Screen for Viral Hepatitis? (Part 2)
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Should DOMs Screen for Viral Hepatitis? (Part 2)

In  Part 1,  I wrote that the Center for Disease Control and Prevention (CDC) recommends routine risk-based screening of baby-boomers (those born between 1945 - 1965) for hepatitis C (HCV). In contrast, the U.S. Preventive Services Task Force (USPTF) Recommendation Statement (2013) stated:

"Given the accuracy of the screening test and the availability of effective interventions for HCV infection, the USPTF concludes that screening is of moderate benefit for populations at high risk for infection. The USPSTF concludes that 1-time screening in all adults in the United States born between 1945 and 1965 is also of moderate benefit..."

However, as of June 2013, the USPTF revised this recommendation to a one-time anti-HCV testing of all baby-boomer. Yet, there is a difference between the USPTF screening tests and the CDC risk-based screening that DOMS can and should provide.

Risk-based Screening vs. Screening Tests
Risk-based screening (or Risk Assessment) identifies who should be referred for HCV screening tests per the USPTF definition [see below]. Risk-based screening consists of:

  • Exposure history questions: past contact with another persons' blood during an accident or injury. 
  • Personal care history questions: were sharing toothbrushes, receiving tattoos or piercings, etc. 
  • Social history questions:  illicit drug use, incarceration, travel abroad, and past and current sexual activity. 
  • Medical history questions: iatrogenic risks for transmission, including blood transfusions, dialysis, medical procedures. As well as evaluation of liver function tests results.

The Department of Health and Human Services has an online Viral Hepatitis Risk Assessment widget. Providers can complete it or patients can be referred to it to complete themselves. Upon completion, a printable recommendation with rationale for further follow-up screening tests; or no further follow-up screening tests is given. The USPTF defines HCV follow-up screening tests as: 

Qualitative serum Anti–HCV antibody test. This is the test that the USPTF recommends for all Baby-boomers. McGinn et al (2008) write, "Our validation demonstrates that a negative result on a risk assessment tool can eliminate the need for anti-HCV antibody testing in the majority of patients assessed. Furthermore, it can accurately identify those patients at moderately increased risk who would benefit from antibody screening".

Quantitative viral load polymerase chain reaction test (PCR).

Various noninvasive and serological tests:
  • FibroTest is used to rule-out low grade fibrosis, and high grade fibrosis/cirrhosis (but not moderate grade). 
  • AST Platelet Ratio Index (APRI score) has less discordance for moderate fibrosis (Borsoi-Viana, Takei, Collarile, Guz & Strauss, 2009). 
  • Transient Elastography Score for liver stiffness identifies those at low risk for developing liver failure, or HCC within 2 years (Clinical Care Options, 2013). 
  • (Liver biopsy is invasive, and remains the gold-standard for grading fibrosis, and diagnosing cirrhosis). 


Regarding the USPTF original statement that there was lack of "availability of effective interventions for HCV infection":

The standard treatments for HCV can be curative and has evolved rapidly and drastically. Dual therapy with peginterferon & ribavirin  or Triple Therapy with peginterferon & ribaviirin, plus HCV protease inhibitors was protracted with many side-effects. It was expectedly difficult to tolerate these treatments at maximum dose & duration without many side effects. There was varying protocols with varying degrees of effectiveness depending on the HCV genotype being treated. However, treatment with new drugs such as Boceprevir and Telaprevir are much more efficient with less if any side effects to hinder compliance. There is also less disparity between the effectiveness of these new drugs for different HCV genotypes.


References
Borsoi- Viana, M., Takei,K.,  Collarile, Y., Guz, B., Strauss, E. (2009). Use of AST platelet ration index
     (APRI Score) as an alternative to liver biopsy for treatment indication in chronic hepatitis C.
     Annuals of Hepatology 8(1), 26- 31.
Clinical Care Options. (2013). Screening for HCV and initial care of newly diagnosed patients.
     Annual Report.
U.S. Preventive Services Tak Force. (2013). Screening for hepatitis C virus infection in adults. U.S.:    
     Preventive Services Task Force recommendation statement. Retrieved from     
     http://www.uspreventiveservicestaskforce.org/uspstf12/hepc/hepcfinalrs.htm#summary
McGinn, T., Connor-Moore, N., Alfandre, D.,; Gardenier, D.,; Wisnivesky, J. (2008). Validation of a    
     hepatitis C screening tool in primary care. Archives of Internal Medicine 168(18), 2009-2013.    
     Retrieved from http://natap.org/2010/HCV/021110_01.htm













  


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