Recommendations for the Identification of Chronic Hepatitis C Virus Infection Among Persons Born During 1945–1965

Recommendations and Reports
August 17, 2012 / 61(RR04);1-18

Prepared by

Bryce D. Smith, PhD1

Rebecca L. Morgan, MPH1

Geoff A. Beckett, PA-C, MPH1

Yngve Falck-Ytter, MD2

Deborah Holtzman, PhD1

Chong-Gee Teo, MD, PhD1

Amy Jewett, MPH3

Brittney Baack, MPH3

David B. Rein, PhD4

Nita Patel, PhD6

Miriam Alter, PhD5

Anthony Yartel, MPH6

John W. Ward, MD1

1Division of Viral Hepatitis, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention

2 Case Western Reserve University, Case and VA Medical Center, Cleveland, Ohio

3Oak Ridge Institute for Science and Education, Oak Ridge, Tennessee

4NORC at the University of Chicago, Atlanta, Georgia

5University of Texas Medical Branch, Galveston, Texas

6Centers for Disease Control and Prevention Foundation

Corresponding preparer: Bryce D. Smith, PhD, Division of Viral Hepatitis, 1600 Clifton Rd, NE, MS G-37, Atlanta, GA 30329. Telephone: 404-639-6277; Fax: 404-718-8588; E-mail: bsmith6@cdc.gov.

Summary

Hepatitis C virus (HCV) is an increasing cause of morbidity and mortality in the United States. Many of the 2.7–3.9 million persons living with HCV infection are unaware they are infected and do not receive care (e.g., education, counseling, and medical monitoring) and treatment. CDC estimates that although persons born during 1945–1965 comprise an estimated 27% of the population, they account for approximately three fourths of all HCV infections in the United States, 73% of HCV-associated mortality, and are at greatest risk for hepatocellular carcinoma and other HCV-related liver disease. With the advent of new therapies that can halt disease progression and provide a virologic cure (i.e., sustained viral clearance following completion of treatment) in most persons, targeted testing and linkage to care for infected persons in this birth cohort is expected to reduce HCV-related morbidity and mortality. CDC is augmenting previous recommendations for HCV testing (CDC. Recommendations for prevention and control of hepatitis C virus (HCV) infection and HCV-related chronic disease. MMWR 1998;47[No. RR–19]) to recommend one-time testing without prior ascertainment of HCV risk for persons born during 1945–1965, a population with a disproportionately high prevalence of HCV infection and related disease. Persons identified as having HCV infection should receive a brief screening for alcohol use and intervention as clinically indicated, followed by referral to appropriate care for HCV infection and related conditions. These recommendations do not replace previous guidelines for HCV testing that are based on known risk factors and clinical indications. Rather, they define an additional target population for testing: persons born during 1945–1965. CDC developed these recommendations with the assistance of a work group representing diverse expertise and perspectives. The recommendations are informed by the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework, an approach that provides guidance and tools to define the research questions, conduct the systematic review, assess the overall quality of the evidence, and determine strength of the recommendations. This report is intended to serve as a resource for health-care professionals, public health officials, and organizations involved in the development, implementation, and evaluation of prevention and clinical services. These recommendations will be reviewed every 5 years and updated to include advances in the published evidence.

Introduction

In the United States, an estimated 2.7–3.9 million persons (1.0%–1.5%) are living with hepatitis C virus (HCV) infection (1), and an estimated 17,000 persons were newly infected in 2010, the most recent year that data are available (2). With an HCV antibody prevalence of 3.25%, persons born during 1945–1965 account for approximately three fourths of all chronic HCV infections among adults in the United States (3). Although effective treatments are available to clear HCV infection from the body, most persons with HCV do not know they are infected (4–7), do not receive needed care (e.g., education, counseling, and medical monitoring), and are not evaluated for treatment. HCV testing is the first step toward improving health outcomes for persons infected with HCV.
Since 1998, routine HCV testing has been recommended by CDC for persons most likely to be infected with HCV (8) (Box). These recommendations were made on the basis of a known epidemiologic association between a risk factor and acquiring HCV infection. However, many persons with HCV infection do not recall or report having any of these specific risk factors.
In a recent analysis of data from a national health survey, 55% of persons ever infected with HCV reported an exposure risk (e.g., injection-drug use or blood transfusion before July 1992), and the remaining 45% reported no known exposure risk (CDC, unpublished data, 2012). Other potential exposures include ever having received chronic hemodialysis, being born to an HCV-infected mother, intranasal drug use, acquiring a tattoo in an unregulated establishment, being incarcerated, being stuck by a needle (e.g., in health care, emergency medical, home, or public safety settings) and receiving invasive health-care procedures (i.e., those involving a percutaneous exposure, such as surgery before implementation of universal precautions). Although HCV is inefficiently transmitted through sexual activity, the prevalence of HCV antibodies among persons who report having had ≥20 sex partners is 4.5 times greater compared with the general population (1).
These birth-year-based recommendations are intended to augment, not replace, the 1998 HCV testing guidelines (8). They were developed by the HCV Birth Cohort Testing Work Group, which consisted of experts from CDC and other federal agencies, professional associations, community-based organizations, and medical associations. The Work Group used the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework (9–17) to inform the development of these recommendations. The GRADE approach provides guidance and tools to define the research questions, conduct systematic reviews, assess the overall quality of the evidence, and determine the direction and strength of the recommendations. Following this evidence review, CDC's Division of Viral Hepatitis (DVH) developed this report, which was then peer-reviewed by external experts and posted for public comment (www.regulations.gov). CDC reviewed and considered all public comments in developing the final recommendations.