Is Mass HCV Screening the Best Approach?

[Hep Talk]

Calling All Boomers
New analysis questions the need for mass HCV screening
by Larry Buhl


In 2012, the U.S. Centers for Disease Control and Prevention (CDC) recommended screening everyone born between 1945 and 1965—the so-called Baby Boom generation—for the hepatitis C virus (HCV) whether or not they think they were exposed to the virus.
The assumption is that large-scale cohort screening would catch many more cases of infection with HCV than risk-based testing (IV drug users, transfusion recipients before 1992). It’s been estimated that three quarters of all people infected with HCV are Boomers.

In October 2013, New York passed legislation making it the first state requiring all hospitals to offer testing to all patients born between 1945 and 1965. In addition, the U.S. Preventive Services Task Force and World Health Organization also recommends Boomer cohort screening.

But a paper published in January, 2015, in the British Medical Journal says there’s little concrete evidence that screening all Baby Boomers for hepatitis C would save lives and that aggressively screening of all Boomers would cause many people to be treated unnecessarily with potentially physically debilitating meds.

The authors write that since many people infected with hepatitis C never develop symptoms and will die from other causes, exposing them to the harms of treatment might outweigh the benefits for the minority who develop end stage liver disease, such as decompensated cirrhosis or hepatocellular cancer.

And they conclude that, “given the uncertainty about the validity of the surrogate markers, the lack of evidence regarding clinical outcomes of treatment or of screening strategies, and the adverse events caused by the newer regimens, screening may be premature.”

The authors of the BMJ article, led by Dr. John Ioannidis, a Stanford epidemiologist, point out that their conclusions are not based on new data, but rather an analysis of existing evidence and commentary on the implications for birth cohort screening.

And they admit that their analysis is not definitive, just that there is not enough evidence to show that Boomer screening is the best approach to fighting the virus. They call for research before what one author calls “an uncontrolled screening experiment involving the entire Baby Boomer generation.”

Kenneth Lin, a Georgetown University associate professor of family medicine and co-author of the paper says that there is always the potential for harm in screening for any disease.

“If you tell someone they have diabetes or breast cancer, their quality of life immediately worsens,” Lin tells A&U.
“That doesn’t mean we shouldn’t screen for those things in certain populations, because the benefits generally outweigh these harms. We point out that at least eighty percent of persons with hepatitis C will not suffer symptoms or die from liver disease and therefore cannot personally benefit from screening or treatment and that testing and treatment can only harm them.”

The conclusions from the article are drawing some boos from the hepatitis advocacy community.

Emalie Huriaux, MPH, Director of Federal & State Affairs for Project Inform says the BMJ authors’ conclusions are misguided and not helpful in the fight against hepatitis.

“The assumptions [in the article] are just wrong-headed,” Huriaux tells A&U.

“First of all, end-stage liver disease was the authors’ only marker concern, but that ignores other quality of life issues for people who have hepatitis C. It’s a systemic disease and there are gastrointestinal issues, metabolic issues, fatigue and confusion.”

The second problem, Huriaux says, is the authors are concerned about the debilitating effects of hepatitis treatments that are, or will soon become, obsolete.

“At least in North America, treatments like boceprevir and telaprevir, and especially interferon, will be phased out soon as more effective treatments become widely available.”

Huriaux adds that, even if the only marker of concern is end-stage liver disease, you can’t prevent that without knowing whether a person has the virus or not. “By the time the virus has progressed that far, it’s done a lot of damage.”

Lin adds that the risk-based approach to testing still makes the most sense, though he says he isn’t speaking for his colleagues.

“It’s nearly impossible to acquire HCV without having used IV drugs or having been on hemodialysis or received a blood transfusion before 1992.”

Huriaux responds by asking who would pay for such a study of screening effectiveness when there is already little federal investment in the continuum of care for those infected with HCV.

“The issue isn’t whether we should screen [Boomers], but what are the best ways to do it. And right now the obstacle is political will. There is very little federal or state money for testing or treatment. Which is pretty crazy because we now have meds with a greater than ninety percent effectiveness rate.”

Until money for screening, care and quality measurements is available, Huriaux says, analyses like those in the British Medical Journal article are “just distractions.”

Larry Buhl is a radio news reporter, screenwriter, and novelist living in Los Angeles. His podcast on employment issues, “Labor Pains,” can be found at