May is HEPATITIS AWARENESS month- did you know? The CDC launched its “kNOw MORE Hepatitis” campaign, complete with National Hepatitis Testing Day on May 19th. The information is designed to increase awareness of signs, symptoms, treatment and testing for this often silent, yet progressive, set of infections.
What’s new for physicians? The CDC has estimated that 1 in 30 Americans in the “Baby Boomer” age group (defined as anyone born 1945-1965) is infected with Hepatitis C, and they have therefore proposed changing guidelines to recommend universal screening for this age group. Although a high estimate, given only an estimated 16,000 new infections were reported in 2009, part of the explanation for this recommendation is most Baby Boomers would have been infected in their teens or early twenties, and are only now showing the effects of chronic disease. Current statistics show 75% of new infections are being detected in this age group, and over 15,000 deaths per year are linked to Hep C-related end stage illnesses. We know even a remote history of IV drug abuse is a risk factor for Hep C, but remember blood transfusions prior to 1992 also add risk, and most importantly, roughly 10% of patients diagnosed with hepatitis C have no identifiable risk factors. Additionally, the CDC recognizes the new treatments for Hep C have tripled the cure rate.
What tests should we order? The initial screen should be an Anti-HCV Ab. If this is negative, you are done. If positive, the next test is either HCV RNA or RIBA for anti-HCV. If either of these tests is positive, you should proceed with a full evaluation for active infection and extent of liver disease. If the HCV RNA is negative, test the RIBA next. If you receive an “indeterminate” reading for the RIBA anti-HCV, wait at least a month and repeat the second level of testing. (See the CDC Flow Chart for more details.) Positive tests should be reported to the health department.
False positives (which will occur more often in low risk populations) will be identified with a positive Anti-HCV Ab but a negative Anti-HCV RIBA. No further evaluation is needed for these.
True positive Anti-HCV Ab with positive Anti-HCV RIBA but negative HCV RNA can be difficult to explain to the patient. We know this can indicate either past disease that has “cleared” (true in 15-25% of infections) or they may have a carrier state or more active disease, as viral loads can fluctuate.
Treatment decisions will be based upon severity of liver disease, patient symptoms, and HCV Genotype. Different genotypes have distinctly different responses to therapy, and the newer medications have not only improved prognosis (curing up to 75%) but have fewer side effects. Let’s help our patients (and our peers) to indeed, kNOw MORE about Hepatitis!
- Jill A. Grimes, MD