文章基本信息

标题：Comparison of Current US Risk Strategy to Screen for Hepatitis C Virus With a Hypothetical Targeted Birth Cohort Strategy
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作者：Kenneth J. Tomaszewski ; Baris Deniz ; Peter Tomanovich 等
期刊名称：American journal of public health
印刷版ISSN：0090-0036
出版年度：2009
卷号：102
期号：11
页码：e101-e106
DOI：10.2105/AJPH.2011.300488
语种：English
出版社：American Public Health Association
摘要：Objectives. We compared the theoretical performance of a 1-time, birth cohort strategy with the currently recommended risk strategy for screening for hepatitis C virus (HCV) infection, which is undetected in an estimated 75% of 4 million affected people in the United States. Methods. We applied current American Association for the Study of Liver Disease risk screening guidelines and a targeted birth cohort strategy to National Health and Nutrition Examination Survey data from 2003 to 2006 to estimate their performance in identifying HCV cases. Results. Risk guidelines would recommend testing 25% of the US population aged 20 years or older and, if fully implemented, identify 82% of the projected HCV-exposed population. A targeted birth cohort (1946–1964) strategy would test 45% of the same population and identify 76% of the projected HCV population. Conclusions. In this ideal-world simulation, birth year and risk screening had similar theoretical performances for predicting HCV infection. However, actual implementation of risk screening has not achieved its theoretical performance, and birth cohort screening might increase HCV testing rates. An epidemic of hepatitis C virus (HCV) acquisition occurred between the 1960s and the 1980s in the United States; at its peak, an estimated 250 000 persons per year were newly infected. Since 1990, new cases of HCV infection have declined by 90%, and it is estimated that fewer than 20 000 persons a year are becoming infected. 1,2 Up to 4 million persons in the United States are estimated to be chronically infected with HCV, making it the most common blood-borne infection. 1–3 Chronic HCV infection strikes a narrow age range: more than two thirds of those affected were born between 1946 and 1964. 2,4,5 As of 2010, the majority of these persons have been living with HCV for 20 to 40 years. The natural history of chronic HCV infection is characterized by a long period (usually > 20 years) in which individuals are relatively asymptomatic and often lack signs indicative of chronic liver disease. 4,6 During this time, chronic liver inflammation and fibrosis progress, 2,7 and severe fibrosis and cirrhosis can develop before liver disease is diagnosed. 1,2,8,9 Only 15% of affected individuals will have persistently elevated liver enzymes during the asymptomatic period, and intermittently elevated liver enzyme levels may not be appreciated as a potential sign of chronic HCV infection. 8 The majority of persons who have chronic HCV have been infected for more than 20 years; an estimated 25% of them (∼800 000 persons) have developed cirrhosis, and approximately 40% have developed moderate to severe fibrosis. 2 These persons are at risk for decompensated liver disease (ascites, gastroesophageal variceal hemorrhage, or hepatic encephalopathy), 8 hepatocellular carcinoma, 2,10 liver transplantation, 2,10 and liver-related death. 2,4,5 Cases of liver decompensation and hepatocellular carcinoma are expected to increase dramatically over the next 10 to 13 years, and annual liver-related deaths are projected to increase by 74%, from 145 667 in 2010 to 254 550 in 2019. 2 Total medical costs for HCV-infected patients are also expected to increase dramatically over the next 20 years, from $30 billion in 2009 to $85 billion in 2028. 5 Current HCV screening practices are based on the assessment of risk factors. The 1998 Centers for Disease Control guidelines, 11 2002 National Institutes of Health guidelines, 12 and 2009 American Association for the Study of Liver Disease (AASLD) guidelines 8 recommend screening individuals who have risk factors such as elevated liver enzymes; blood transfusion before 1992; injection drug use, even once; dialysis treatment, ever; and HIV infection. However, a managed care organization analysis of HCV testing found that only 0.7% of its members received anti-HCV screening over a 3-year period. 13 Another managed care study found that over an 8-year period, only 4.3% of the study population was tested for HCV, and among this group, 5.2% had detectable HCV antibodies. 14 Several groups, including the Institute of Medicine, have estimated that up to three quarters of persons with chronic HCV infection are unaware of their infection. 4–6,15 Suboptimal diagnosis rates may be attributable to shortcomings in the application of screening guidelines in practice. Health care providers do not always ask about HCV risk factors, 16,17 and patients may fail to disclose them because of a lack of knowledge or a fear of stigmatization. 4,18 The 2010 Institute of Medicine report on viral hepatitis recommended large-scale educational campaigns directed at primary care providers, the general public, and those most at risk for HCV, which would raise disease awareness and address the knowledge gaps and stigma associated with HCV infection. 4 More than half of persons with HCV infection remain undiagnosed despite 12 years of experience with risk factor screening guidelines. 4–6,15 Because HCV infection affects certain birth cohorts disproportionately, we explored the potential effectiveness of 1-time HCV screening of a targeted birth cohort in increasing diagnosis rates in the United States. We compared the birth cohort screening strategy with the current risk strategy for the proportion of HCV-infected persons that would be detected and the total number that would be tested.