A Canadian screening program for hepatitis C: Is now the time?

Abstract

Analysis CMAJ• Hepatitis C virus (HCV) infection has an enormous impact on population health in Canada and is likely underdiagnosed.• A national strategy to screen for and treat HCV infections would substantially reduce HCV-related morbidity and mortality.• Birth-cohort screening of people born between 1945 and 1975 coupled with a strategy for follow-up treatment and education is probably the best method to identify and provide care to affected people in Canada.• Population-level data on the prevalence and health impact of HCV infection are needed in Canada. Key points © 2013 Canadian Medical Association or its licensorsCMAJ, October 15, 2013, 185(15) 1325 markedly lower than in countries with active surveillance programs for HCV, and, if correct, would place Canada among the top countries in the world at diagnosing HCV infections despite not having a national screening program. The CDC estimates that 63% of Americans with HCV are unaware of their infection, 7 and underdiagnosis is highly prevalent even among people with insurance and access to care.11 Data from Europe show a similar pattern. Before introducing an intensive national program, 75% of infected individuals in France were unaware of their infection; after introduction of this program, the rate decreased to 44%. 12 Given that it took a major national effort in France to get the diagnosis rate to 56%, it seems unlikely that Canada's estimate that 79% of infected individuals are aware of their diagnosis is correct.The Canadian data may be inaccurate for 2 major reasons. First, diagnosed cases may have been inadvertently counted more than once. Second, and more importantly, the overall prevalence may be considerably higher than estimated, particularly because groups at high risk of HCV infection are often undersampled. With the same number of positive test results, a higher prevalence would lead to a lower diagnosis rate. If Canadian data are similar to those in countries with comparable health care systems (e.g., France), the rate of underdiagnosis is likely much higher than 21%, and strategies to decrease this rate are needed. What are the benefits and risks of screening?Hepatitis C virus meets the criteria for a condition for which screening specific populations is potentially useful. There are many benefits: HCV is a major cause of morbidity and mortality; the prevalence of HCV is increased among baby boomers; many individuals are unaware that they are infected; and HCV infection is curable, with early intervention leading to improved overall health outcomes. Patients whose infection has been eradicated before cirrhosis develops have a life expectancy similar to that of uninfected people.13 If cirrhosis develops before treatment, viral eradication eliminates the risk of liver failure and markedly reduces the risk of hepatocellular cancer. 3,13 There are potential risks associated with screening, including individuals feeling stigmatized by being "targeted," false positive results and a lack of capacity to treat the volume of newly diagnosed cases. ...

Screening and diagnosis of chronic HCV infection in Bulgaria: A review of the current practice

“…If the patients progress to cirrhosis before the treatment initiation, viral eradication would eliminate the risk of liver failure and would significantly reduce the risk of hepatocellular carcinoma [26].…”

Recommendations on hepatitis C screening for adults

“…Reasons for developing this recommendation include the availability of new treatments for chronic HCV infection and the lack of Canadian guidelines for screening. 13 The current recommendations are intended to provide clinicians and policy-makers with guidance on screening asymptomatic Canadian adults for HCV.…”

“…Interferonfree DAA regimens are very costly, but have several advantages: they are administered orally, require shorter treatment duration and have higher likelihood of sustained virologic response, with fewer adverse effects than older regimens. 9 There are no organized HCV screening programs for the general population in Canada, 13 although the Public Health Agency of Canada (PHAC) and the College of Family Physicians of Canada (CFPC) recommend testing for hepatitis C in people at elevated risk for HCV. 14 …”

Cost-effectiveness of screening for hepatitis C in Canada

“…These complications may be reduced by offering timely treatment. 2 In the United States, recently revised screening recommendations suggest that those born between 1945 and 1965 should be screened. 3 It would be helpful to ascertain whether these US recommendations would be cost-effective in Canada, given differences in epidemiology of the disease and in health care systems between the 2 countries.…”

“…3 It would be helpful to ascertain whether these US recommendations would be cost-effective in Canada, given differences in epidemiology of the disease and in health care systems between the 2 countries. 2 The issue of cost is particularly salient because several new, effective but expensive regimens for treating chronic HCV infection are in development. 4 The markedly improved tolerability of these new regimens and the anticipated high cure rates are likely to increase substantially both treatment uptake and overall treatment costs.…”