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Why primary care physicians should be setting up a screening program.
An estimated 2.4 million people in the United States are living with hepatitis C, and in 2016, the Centers for Disease Controls and Prevention (CDC) reported approximately 18,000 U.S. deaths were the result of the hepatitis C virus (HCV) as an underlying or contributing cause. And the CDC believes that number is a low estimation of what the true figure is.
The problem is, a majority of those living with the virus don’t even know they have it.
That’s why the CDC recommends one-time screening for hepatitis C for Baby Boomers (those born between 1945 and 1965), regardless of apparent risk factors.
Yet despite the recommended guidelines, only a small fraction of this segment has actually been screened. For that reason, it’s vital that primary care physicians play a more active role.
Alexea M. Gaffney, MD, an internist in Stony Brook, N.Y., says hepatitis C screening is so important because the vast majority of individuals with the infection will have no symptoms or will have symptoms that physicians describe as “extra-hepatic” outside of the liver.
“Without screening, we miss the opportunity to treat and cure this infection before patients or infected individuals become symptomatic or progress to irreversible liver disease or scarring such as cirrhosis or develop cancer of the liver,” she says. “We also miss the opportunity to prevent liver failure and the need for liver transplants in significant numbers of patients.”
Janette Nesheiwat, MD, a family doctor and the medical director at City MD, which operates more than 100 urgent care centers, says some routes of transmission include sexual activity, intravenous drug use, mother to child during pregnancy, a needlestick injury or blood transfusions.
“Early detection and screening is important because there is a better success rate and outcome if the disease is caught early before severe symptoms and complications occur. Early detection lowers the risk of worsening complications, such as a need for liver transplant, or cancer formation and death,” she says. “This is why doctors urge screening.”
PCPs Need To Step Up
Rusha Modi, MD, MPH, assistant professor of clinical medicine at Keck School of Medicine of the University of Southern California, says as an academic gastroenterologist and hepatologist, he sees a wide range of patients with HCV-from those asymptomatic to those that need lifesaving transplants.
“Now that we have effective treatments that can eradicate the virus, there is an opportunity for people to advance their health and prevent long-term complications,” he says. “It doesn’t make sense that people aren’t being screened.”
Primary care physicians can be a solution to this problem and take action at their practices.
“They can make inquiries by asking qualifying questions to patients during new patient visits, annual exams or wellness visits,” Gaffney says. “They could also give a questionnaire to patients asking if they meet any of the criteria. A single yes means a patient needs to be screened. The test can be ordered alone or with other routine blood work.”
The criteria checklist includes those who currently or in the past have shared needles for intravenous drug use or straws for intranasal drug use; have received tattoos or body piercings from an unlicensed facility; were treated for a blood clotting disorder such as hemophilia before 1987; received a blood or blood product transfusion or organ transplant before July 1992; are on long-term hemodialysis treatment; have abnormal liver function tests or liver disease; or work in healthcare or law enforcement and were exposed to blood through a sharp object, injury, or bite.
Mark Shaffer, MD, a family physician and clinical assistant professor of family & preventive medicine at the University of South Carolina, says the simplest approach to set up hep C screening in the primary care office is to integrate it in the same ordering and tracking mechanism used for mammograms, colonoscopies and other preventive care services at the adult health maintenance exam.
“Most electronic medical records have a mechanism for this,” he says. “One challenge, however, is that many providers seeing patients feel too far removed from the people actually programming their EHR, especially in large systems, to drive effective changes. Another challenge is that many patients do not attend an annual health maintenance exam, which is currently the only dedicated moment for a provider to review their record and preventive care needs.”
This has led to a lot of direct to patient advertising for other preventive care measures, like mammograms, and Shaffer suspects the same is needed to improve hep C screening as well.
Gaffney says providers need to inform Baby Boomers that they account for three out of four patients infected with HCV, explaining that they received healthcare before universal precautions became standard for medical care.
This is not always as easy as it sounds, however.
“Sometimes physicians do not want to risk making patients feel ‘judged’ by them, so they may not ask appropriate questions to assess for hep C risk,” she says. “They also may not understand that patients can be asymptomatic and have a normal exam and lab analysis and still have hepatitis C infection.”
Additionally, patients will sometimes decline tests when they do not understand their risk factors for a disease process, especially a transmissible infection.
“It’s a challenge for many due to busy hectic lifestyles and the misunderstanding that, ‘It can’t happen to me,’” Nesheiwat says. “Well, all it takes is one encounter to acquire hep C.”
Aaron Eli Glatt, MD, chair of medicine at South Nassau Communities Hospital in Oceanside, N.Y., and a spokesperson for the Infectious Disease Society of America, says while screening is essential for Baby Boomers, hepatitis C can impact all sorts of different populations, especially those younger generations that were involved in substance abuse. He says physicians should be talking about the dangers of HCV with all of their patients.
He explains that often the virus will go unrecognized until there are symptoms, and while it can still be cured easily, some complications that develop might not be so easily fixed, which is why screening needs to be done before the virus kicks in.
Glatt believes the reason more people don’t get screened comes down to apathy.
“For most people, and I think this is especially true of the Baby Boomer population, if they aren’t sick, they feel they don’t have the time to be screened and it’s not a priority,” Glatt says. “PCPs just need to stress the importance of this screening and their patients have to agree to have the screening done. That could solve so many problems.”
Glatt says that a simple blood test can be an indicator if screening is necessary and no patients should be scared off from that.
“There’s a 98 percent cure rate, and there are very few diseases with those kind of numbers,” he says. “It’s expensive, but insurance usually covers it. A simple pill once a day for eight weeks can cure it. If someone is in the Baby Boomer range, it makes all the sense in the world to be screened.”