Screen all baby boomers for hepatitis C, says new guideline

As many as a quarter of a million Canadians are infected with the hepatitis C virus. A new guideline just published in the Canadian Medical Association Journal could help eradicate the disease in this country.

A blue-ribbon panel of experts has recommended that all Canadians born between 1945 and 1975 be tested for hepatitis C.

Doctors say those born before 1945 and after 1975 should get tested if they're at high risk of contracting the virus. 

Those factors include being HIV positive, having a history of current or past injection drug use, receiving a blood transfusion or blood products or organ transplant in Canada before 1992, current or prior history of being incarcerated, a history of receiving health care where there's a lack of infection control practices, and a history of being born or residing in a country with a high prevalence of hepatitis C. 

There are strong reasons why doctors are recommending universal testing for baby boomers. Currently, they estimate that a quarter of a million Canadians are chronically infected with the virus.

People born between 1945 and 1975 have the highest prevalence of the disease. Up to 70 per cent of them don't know they're infected because they've never been tested and because hepatitis C is a silent disease until complications arise.

The previous guideline recommended testing only high-risk Canadians of all ages. The problem with that approach is that it's likely to miss many of the baby boomers who are infected, hence the change to universal testing in that age group.

The other reason for testing all baby boomers is that the cost of testing and treatment have gone down to the point that it's worth the price.

Treatment is generally considered both effective against the virus and safe. The previous drug treatments had lots of side effects. Most patients tolerate the newer treatments quite well.

The new guideline says all patients diagnosed with chronic hepatitis C are candidates for antiviral medications. There are several different subtypes of hepatitis C, and treatments vary with the subtype.

Health Canada has approved eight antiviral treatment regimens. Until recently, the treatments were quite expensive.

In 2017, the pan-Canadian Pharmaceutical Alliance (pCPA) negotiated reduced prices of five of the drug regimens. The pCPA is an agency that facilitates joint negotiation of prescription drug prices.

There is a lot riding on the new guidelines being followed by doctors on the front lines. 

Screening and treating patients

What's at stake is the possibility of curing hepatitis C, or at least slowing its progression and preventing complications such as cirrhosis of the liver and death. Widespread treatment of infected Canadians would also be expected to reduce the demand for liver transplants.

Proponents say the guidelines offer the best hope for curing the infection and preventing complications. In a related commentary also published in CMAJ, experts said 95 per cent of those receiving antiviral treatment have a sustained response, which is considered the equivalent of a cure.

Still, critics point to a Cochrane review that casts doubt on the effectiveness of direct-acting antiviral agents. That paper has been strongly criticized by groups such as the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America. 

The authors of the guideline say there are gaps in knowledge. While the vast majority of people infected can be treated successfully, they can't cure everyone.

There are limited treatment options for patients with advanced cirrhosis. Preventing new infections and screening younger patients are essential.

Making the new types of treatment available to all Canadians is another challenge.Some regions in Canada continue to limit access for those in whom the virus has caused scarring of the liver. These are restrictions the authors of the guideline say should be lifted based on current evidence. 

Another challenge is for the health-care system to find and treat all patients at high risk, especially those born in countries where infections are common, Indigenous people, patients with addiction disorders, and those who are incarcerated.

The World Health Organization has set a goal of eliminating hepatitis C by the year 2030. Data released at the 2017 World Hepatitis Summit found that only Australia, Brazil, Egypt, Georgia, Germany, Iceland, Japan, the Netherlands and Qatar are on course to meet that goal. The authors say Canada needs a national action plan to meet that goal.

It's time that Canada step up to meet the challenge.