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    When and How to Screen for Hepatitis C

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    Hepatitis C is a chronic systemic viral infection that mainly impacts the liver. The disease is responsible for significant morbidity and mortality yearly.

    As technology has advanced, new drugs now offer excellent clinical responses, which can prevent the rate of cirrhosis and end stage liver disease.

    New guidelines indicate the importance of screening for hepatitis C in asymptomatic individuals. In this case, saving a life can be as simple as having a conversation.

    In 2012, the CDC reported  a sharp rise in the number of cases of Hepatitis C. Accordingly, the United States Preventive Services Task Force (USPSTF) began making recommendations for screening in asymptomatic individuals.

    Early screening has been shown to favor a better clinical response while later diagnosis is associated with increased rates of hospitalization and death.

    This article will review the indications of screening for chronic Hepatitis C infection in asymptomatic adults. As the disease becomes more prevalent in our population, it will become more important for clinicians across all specialties to recognize the importance of screening.

    The screening process is paramount because the vast majority of patients with hepatitis C are asymptomatic. Unless cirrhosis or symptoms of end stage liver disease are present, this disease remains undiscovered until far into it’s’ progression.

    An estimated 50% of patients infected with the disease are unaware of the diagnosis. Upon diagnosis, up to 45% of patients may not even recall how the disease was transmitted.

    The largest population to benefit from screening interventions is that of the “baby boomers”, or persons born between 1945 and 1965. An estimated 3 million baby boomers may have Hepatitis C and be entirely unaware. This not only increases the risk of progression of the disease, but also transmission to others.

    The USPSTF makes a Grade B recommendation for screening in this population.

    Other specific populations whom may benefit from screening include those infected with HIV, dialysis patients, and the incarcerated. There is a high coinfection between HIV and Hepatitis C.

    It is important to note the specific risk factors for transmission of disease. Although being a “baby boomer” is a risk factor, other risk factors can be present to help affirm the decision to screen.

    Additional risk factors include intravenous drug use, nasal drug use, unregulated tattoos, blood transfusion/organ transplant prior to 1992, exposure to a patient with HCV infection, and sexual promiscuity.

    Preventing spread of a hepatitis C infection is additionally important. Prevention of transmission includes avoiding IV drug use, avoiding sharing needles, and safe sexual practices. Patients with hepatitis C should be encouraged not to share tooth brushes, razors, or other items with others.

    The decision to screen should begin with a simple conversation between clinician and patient. The topic can be somewhat difficult to discuss, as patients may not want to admit past or current behaviors such as IV drug use.

    Having a candid, honest conversation is important to risk stratify your patient and determine the need for screening. Education is important, as many patients do not know much about Hepatitis C or the risk factors for transmission.

    Many patients will agree to test if they are in the USPSTF age range. It is important to always consider that other patients outside of this age range still may have significant risk factors for Hepatitis C.

    Screening should be based on the individual level.  It is important to consider screening for the patient with elevated liver enzymes of unknown origin to rule out hepatitis C as a cause.

    Educating patients that the majority of Hepatitis C is asymptomatic is additionally important because patients may not understand the need to screen for a disease if they are feeling healthy or show no symptoms of disease.

    Once the decision is made to screen, a simple lab order to check for Hepatitis C antibodies can be ordered. Most laboratories will have a reflex Hepatitis C RNA if there is a positive antibody. A positive antibody but negative RNA indicates a previous exposure that was cleared by the body’s immune system. A positive RNA should be referred out to a local gastroenterologist who specializes in the treatment of Hepatitis C.

    Genotyping can be ordered prior to referral to assure swift transition to treatment.

    Shared decision making remains an important part of screening patients for Hepatitis C infection. Risk factors, age group, and many other factors should influence the decision to screen. However, in the asymptomatic individual with risk factors, convincing your patient to take a trip to the lab just may save their life.

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    Daniel Champigny, PA-C is a 2016 graduate of The Pennsylvania State University. Prior to attending PA school, Dan worked in pre-hospital medicine as an EMT. Currently, he's in primary care/family medicine in rural Pennsylvania and also works in urgent care. He is a certified impact consultant and is passionate about the management and treatment of concussions. Dan additionally has interests in preventive care, evidence based medicine, and teaching. In his spare time, Dan enjoys running and hiking.