Baby boomers omitted in guidelines for hep C screening

The average Canadian adult does not need to be screened for infection with hepatitis C, a blood-borne virus that can in time cause cirrhosis or cancer of the liver, says a task force that develops practice guidelines for primary-care providers.

In its first hepatitis C screening guidelines released Monday, the Canadian Task Force on Preventive Health Care recommends against widespread testing of adults unless they are considered to have an elevated risk for the disease.

Canadians at high risk include those who: have a history of IV drug use; were born, travelled or resided in countries where hepatitis C is endemic; received blood transfusions or had an organ transplant before 1992, when blood donations weren’t tested for the virus; or could have been exposed through potentially hazardous sexual behaviours or by getting a tattoo.

Dr. Roland Grad, chair of the task force working group that developed the guidelines, said two systematic reviews of the medical literature found no evidence of benefit from widespread screening for hepatitis C among low-risk adults.

“What we are saying is that people who are not at an elevated risk don’t need to go for a blood test or be screened for hepatitis C,” said Grad, an associate professor of medicine at McGill University with a family practice in Montreal. “But if you are at elevated risk, you should be tested.”

Still, one component of the guidelines is sure to be contentious: the task force recommends against routine hepatitis C screening for baby boomers.

“The reason why we could not recommend screening all baby boomers in Canada is that there is no direct scientific evidence that doing that is going to lead to more benefit than harm,” said Grad.

“In fact, there’s now some evidence coming out of the United States that screening of baby boomers in the U.S. does not provide better clinical outcomes.”

That advice runs counter to what many Canadian doctors have been preaching — that those born between 1945 and 1965 should be tested for hepatitis C, a recommendation mirrored in 2012 guidelines from the U.S. Centers for Disease Control (CDC) and the U.S. Preventive Services Task Force.

“The burden of disease related to hepatitis C in North America is currently increasing and in fact is larger than the burden of disease posed by all other reportable infectious diseases,” including tuberculosis and HIV, said Dr. Julio Montaner, director of the BC Centre of Excellence in HIV/AIDS.

Montaner said it was thought that baby boomers infected with the virus likely contracted it during their teens or early 20s, due to IV drug use or sexual experimentation. But a study last year by his research team in conjunction with the CDC found that a high proportion were infected as children and the virus was largely spread “iatrogenically” — meaning it resulted from exposure through inadequately sterilized reusable syringes and needles, for instance, those used in dental freezing and vaccinations.

An estimated 250,000 Canadians are infected with hepatitis C, according to the Canadian Liver Foundation. Many people who become infected never develop symptoms and recover completely. Others get a brief, acute illness with fatigue and jaundice, in which the skin and eyes turn yellow.

However, others can develop chronic hepatitis, which can lead to liver scarring (cirrhosis), liver failure and even liver cancer later in life. Chronic hepatitis C is a “silent” disease because symptoms often don’t appear until the liver is severely damaged — a process that can often take decades.

The guidelines appear in Monday’s issue of the Canadian Medical Association Journal.