New Canadian guideline: No screening for hepatitis C in adults not at increased risk
The Canadian Task Force on Preventive Health Care recommends against screening for chronic hepatitis C virus (HCV) in adults at low risk in a guideline published in CMAJ (Canadian Medical Association Journal).
"Given the lack of direct evidence that mass screening is beneficial and that patients identified by screening will either never develop symptoms of hepatitis C, or will remain well for decades after infection, we have recommended against screening for HCV in adults who are not at elevated risk," said Dr. Roland Grad, member of the task force and chair of the guideline work group.
This is the first hepatitis C screening guideline from the task force. The task force looked for the highest-quality scientific evidence available about the effectiveness (benefits and harms) of screening to develop its recommendation. The recommendation is based on the following:
- the low prevalence of hepatitis C in Canada among the general adult population not at elevated risk for chronic infection;
- the lack of direct evidence on the benefits and harms of screening;
- many individuals with chronic hepatitis C identified by screening would not have timely access to anti-viral treatment;
- the potential for harms caused by screening could include labeling, stigma, and difficulties with insurance;
- the low risk of household and sexual transmission of HCV among individuals not at elevated risk, as well as the low risk of transmission through blood products given routine screening of blood and organs; and
- the anticipated increase in harm resulting from diagnosing and treating individuals who screen positive, but would have never developed HCV-related disease during their lifetime.
This recommendation is for people who are not at increased risk of hepatitis C. It does not apply to pregnant women or people at increased risk, including:
- people with current or past history of injection drug use;
- people who have been in jail;
- people who were born, travelled or lived in hepatitis C endemic countries;
- people who have received health care where there is a lack of universal precautions to protect against viral transmission;
- recipients of blood transfusions, blood products or an organ transplant before 1992 in Canada;
- hemodialysis patients;
- people who have had needle stick injuries;
- people who have engaged in other behaviours associated with hepatitis C exposure such as high-risk sexual behaviour, homelessness, intranasal and inhalation drug use, tattooing, body piercing or sharing sharp instruments or personal hygiene materials with someone who is hepatitis C-positive; and
- anyone with clinical clues suspicious for hepatitis C infection.
"The HCV prevalence in most adults in the general Canadian population is low and direct evidence examining the benefits and harms of screening for HCV is not available," write the authors. "Not screening for HCV [in the general population] will help focus our limited health care resources to test (and treat) individuals at elevated risk for HCV and to provide other medical interventions that are of proven to be of benefit."
For tools to help physicians apply this recommendation in practice, please visit: http://www.canadiantaskforce.ca.
In a related commentary http://www.cmaj.ca/site/press/cmaj.170274.pdf, Drs. Geneviève Cadieux and Herveen Sachdeva, Dalla Lana School of Public Health, University of Toronto, write, "there are both knowledge gaps and system-wide barriers to population-based screening for chronic HCV infection currently in Canada. Chief among these are high cost of treatment, limited access to publicly funded treatment and the health inequity that results. Screening is widely considered to be unethical if treatment is either unavailable or unaffordable."
The Canadian Task Force on Preventive Health Care (CTFPHC) develops clinical practice guidelines that support primary care providers in delivering preventive health care. The mandate of the task force is to develop and disseminate clinical practice guidelines for primary and preventive care, based on systematic analysis of scientific evidence.