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Canadian guidelines recommend against HCV screening in low-risk adults
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The Canadian Task Force on Preventive Health Care recommends against screening for hepatitis C virus in low-risk patients, including baby boomers.
The task force said its first-ever guidance for HCV screening, published today in the Canadian Medical Association Journal, was based on several factors, including the low prevalence (between 0.64% and 0.71%) of HCV in the Canadian population not at an elevated risk for chronic infection and the lack of direct evidence on the benefits and harms of screening.
“Given the lack of direct evidence that mass screening is beneficial and that patients identified by screening will either never develop symptoms of hepatitis C, or will remain well for decades after infection, we have recommended against screening for HCV in adults who are not at elevated risk,” Roland Grad, MD, CM, MSc, FCFP, associate professor in the department of family medicine at McGill University in Montreal and member of the task force, said in a news release.
According to the release, Grad and colleagues also based their guidance on the expected lack of access to antiviral treatment for many chronic HCV patients identified through screening; the potential harms associated with screening, including stigma and difficulties with insurance; the low risk for household and sexual transmission or transmission through routinely screened blood products; and the anticipated increase in harm associated with diagnosing and treating patients who were identified through routine screening but would not have developed HCV–related disease.
The task force’s recommendation not to test asymptomatic baby boomers is contrary to guidance issued by some other groups, including the Canadian Liver Foundation, which says all adults born between 1945 and 1975 should be tested once for HCV. Likewise, the CDC and U.S. Preventive Services Task Force (USPSTF) recommend one-time HCV testing for patients born between 1945 and 1965.
Grad and colleagues said their reasons for developing the recommendations included the availability of new treatments for chronic HCV infection and the lack of Canadian guidelines for screening. Their guidance was based on two independent reviews into the effectiveness of screening patients for HCV.
The guidance is meant for patients who are not at an increased risk for HCV infection and does not apply to pregnant women or patients at an increased risk, including those with a history of using injection drugs; those who have been in jail; who were born, traveled or lived in a country where HCV is endemic; or who received a blood transfusion, blood products or organ transplant before 1992 in Canada.
According to a related commentary by Geneviève Cadieux, MD, PhD, and Herveen Sachdeva, MD, MHSc, of the Dalla Lana School of Public Health at the University of Toronto, up to 44% of Canadians with chronic HCV are unaware of their infection.
Cadieux and Sachdeva said the high cost of treatment for HCV infection and limited access to publicly funded treatment have been barriers to population-based screening in Canada but that such screening should be reconsidered in light of negotiations to reduce the price of direct-acting antivirals and emerging evidence on HCV transmission and the long-term benefits of treatment.
“Similar to strategies for HIV testing in North America, it is likely that a combination of risk-based testing and population-based screening will be needed in the future,” they concluded. – by Gerard Gallagher
Disclosure : The authors report no relevant financial disclosures.
Perspective
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Jordan Feld, MD, MPH
With all the progress in hepatitis C, the biggest challenge in the past couple of years has been trying to obtain these very effective therapies for our patients. It was very exciting in Canada to see recent negotiations with the federal government loosen restrictions and allow us to start treating more people with a promise to have universal access for the country in the next 2 years or even less.
This was fantastic news for patients but was followed shortly by less optimistic news. We now have a guideline from the Canadian Task Force on Preventive Health Care for screening recommendations for hepatitis C in Canada. I must admit that I and many of my colleagues were disappointed to see the conclusions of the task force. They reviewed literature on screening and treatment and concluded that screening should not be done in people at low risk.
That, in itself, is somewhat of a self-evident statement and unfortunately not very helpful. The Canadian Liver Foundation previously advocated for baby boomer screening similar to that in the United States with a slightly different birth cohort of 1945 to 1975. That is based on very solid data in Canada showing this is not only effective in identifying HCV, but it is also cost effective. If the prices on new treatments come down — and they may already be there — this could even be cost-saving for our health care system. Screening makes a lot of sense.
How the task force could look at the data and conclude that we should not be screening and we should simply stick to our old paradigm of screening high-risk individuals is really disconcerting. We know that does not work. It has failed in every country in which it has been attempted and every disease in which it has been implemented. This antiquated recommendation is rather disappointing.
It is hoped that clinicians and academics in Canada will look beyond these guidelines and recognize the evidence supporting broader screening. With this recognition, we can move to include risk-based screening but also to advocate for population-based screening likely based on the birth cohort of 1945 to 1975 so we can identify those with HCV. With improved access to treatment, we can get them cured and reduce the public health burden from this illness.
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