Learning Objectives and CME/Disclosure Information

This activity is intended for healthcare providers delivering care to women and their families.

After completing this activity, the participant should be better able to:

1. Discuss the new USPSTF screening guidelines for HCV infection
2. Describe the typical signs and symptoms of acute and chronic hepatitis C

Estimated time to complete activity: 0.5 hours

Faculty:

Susan J. Gross, MD, FRCSC, FACOG, FACMG President and CEO, The ObG Project

Disclosure of Conflicts of Interest

Postgraduate Institute for Medicine (PIM) requires instructors, planners, managers and other individuals who are in a position to control the content of this activity to disclose any real or apparent conflict of interest (COI) they may have as related to the content of this activity. All identified COI are thoroughly vetted and resolved according to PIM policy. PIM is committed to providing its learners with high quality CME activities and related materials that promote improvements or quality in healthcare and not a specific proprietary business interest of a commercial interest.

Faculty: Susan J. Gross, MD, receives consulting fees from Cradle Genomics, and has financial interest in The ObG Project, Inc.

Planners and Managers: The PIM planners and managers, Trace Hutchison, PharmD, Samantha Mattiucci, PharmD, CHCP, Judi Smelker-Mitchek, MBA, MSN, RN, and Jan Schultz, MSN, RN, CHCP have nothing to disclose.

Method of Participation and Request for Credit

Fees for participating and receiving CME credit for this activity are as posted on The ObG Project website. During the period from 03-23-2020 through 03-23-2021, participants must read the learning objectives and faculty disclosures and study the educational activity.

If you wish to receive acknowledgment for completing this activity, please complete the post-test and evaluation. Upon registering and successfully completing the post-test with a score of 100% and the activity evaluation, your certificate will be made available immediately.

For Pharmacists: Upon successfully completing the post-test with a score of 100% and the activity evaluation form, transcript information will be sent to the NABP CPE Monitor Service within 4 weeks.

Joint Accreditation Statement

In support of improving patient care, this activity has been planned and implemented by the Postgraduate Institute for Medicine and The ObG Project. Postgraduate Institute for Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

Physician Continuing Medical Education

Postgraduate Institute for Medicine designates this enduring material for a maximum of 0.5 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Continuing Nursing Education

The maximum number of hours awarded for this Continuing Nursing Education activity is 0.5 contact hours.

Read Disclaimer & Fine Print

SUMMARY:

• USPSTF has reviewed available evidence and has updated its hepatitis C screening guidance. HCV is the most common chronic blood-borne pathogen in the US with potential for significant morbidity and mortality if left untreated. The prevalence of chronic HCV infection in the US is approximately 1.0% (2013 to 2016), with 44,700 new HCV infections in 2017. There has been an increase in acute infections over the last decade primarily due to increased injection drug use and better surveillance.

• The USPSTF recommends screening for HCV infection in adults aged 18 to 79 years
• Population: All asymptomatic adults aged 18 to 79 years without known liver disease
• B level recommendation
  • Offer or provide this service
  • There is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial

The USPSTF concludes with moderate certainty that screening for HCV infection in adults aged 18 to 79 years has substantial net benefit

Risk Assessment

• Screen all adults ages 18 to 79 years
• Risk factors to consider
  • Injection drug use: Consider screening adolescents <18 years or >79 years
    • Young adults (ages 18 to 30): Approximately 30% are infected
    • Older adults: 70% to 90% are infected
• Pregnancy
  • Screen pregnant adults  

Because of the increasing prevalence of HCV in women aged 15 to 44 years and in infants born to HCV-infected mothers, clinicians may want to consider screening pregnant persons younger than 18 years

Screening Test

• Anti-HCV antibody testing followed by polymerase chain reaction testing for HCV RNA
  • HCV infection can be detected by anti-HCV screening tests (enzyme immunoassay) 4 to 10 weeks after infection
  • Delayed seroconversion may occur in immunocompromised individuals (e.g., those with HIV infection)

Screening Intervals

• “Most adults need to be screened only once”
  • Consider more frequent screening for individuals with ongoing risk (e.g., ongoing injection drug use)
  • Data is limited to determine optimal screening interval for those at continued risk or whether pregnancy impacts need for additional screening

KEY POINTS:

Hepatitis C Overview

• Acute Hepatitis C occurs within the first 6 months after exposure to HCV
• Many individuals will remain asymptomatic
• 15% of patients will spontaneously clear the virus within 6 months
• Signs and symptoms of acute HCV infection
  • Fever | Fatigue | Dark urine | Clay-colored stool | Abdominal pain | Loss of appetite | Nausea and vomiting | Joint pain | Jaundice
  • Most individuals with newly acquired HCV infection will be asymptomatic | 20 to 30% will exhibit symptoms
  • Symptoms will usually appear within 2 to 12 weeks (range: 2–26 weeks) 
• Signs and of chronic HCV infection
  • Most people are asymptomatic or have non-specific symptoms (e.g., chronic fatigue and depression)
  • Many eventually develop chronic liver disease, which can range from mild to severe, including cirrhosis and liver cancer
  • Chronic HCV infection is typically not recognized until asymptomatic people are identified as HCV-positive when screened for blood donation or liver function tests return an abnormal result (e.g., elevated ALT), often during routine evaluation 

Hepatitis C Treatment

Acute

• No treatment required
• Consider treatment if HCV RNA persists after 6 months

Chronic

• Current antiviral therapies can result in sustained virologic response (SVR; absence of detectable virus 12 weeks after completion of treatment)
  • SVR is indicative of a cure of HCV infection
  • Over 90% of HCV infected persons can be cured of HCV infection regardless of HCV genotype with 8-12 weeks of oral therapy
  • CDC provides a link to currently approved FDA therapies to treat hepatitis C (see ‘Learn More – Primary Sources’ below)

Other Professional Recommendations

• AASLD/IDSA
  • One-time, routine, opt out HCV testing is recommended for all individuals aged 18 years and older
  • One-time HCV testing should be performed for all persons less than 18 years old with behaviors, exposures, or conditions or circumstances associated with an increased risk of HCV infection
  • Periodic repeat HCV testing should be offered to all persons with behaviors, exposures, or conditions or circumstances associated with an increased risk of HCV exposure
  • Annual HCV testing is recommended for all persons who inject drugs and for HIV-infected men who have unprotected sex with men
  • As part of prenatal care, all pregnant women should be tested for HCV infection, ideally at the initial visit
• CDC
  • All adults 18 years and older (except in settings where the prevalence is > 0.1%)
  • All pregnant persons should be screened for HCV during each pregnancy (except in settings where the prevalence of HCV infection is > 0.1%)
  • All persons with risk factors (eg., persons with HIV, prior recipients of blood transfusions, persons who ever injected drugs and shared needles, and persons who are born to an HCV-infected mother) should be tested for HCV, with periodic testing while risk factors persist
• SMFM (see ‘Related ObG Topics’ below) has released new guidance supporting the USPSTF/CDC recommendations and states

…we recommend that obstetrical providers screen all pregnant patients for HCV by testing for anti-HCV antibodies in every pregnancy

The timing of when to screen during pregnancy is somewhat arbitrary; screening in the first trimester would theoretically bring the most patients to attention at the earliest time

Learn More – Primary Sources:

Screening for Hepatitis C Virus Infection in Adolescents and Adults – US Preventive Services Task Force Recommendation Statement

AASLD / IDSA: HCV Testing and Linkage to Care

CDC Recommendations for Hepatitis C Screening Among Adults — United States, 2020

CDC link to FDA therapies to treat hepatitis C

Hepatitis C Questions and Answers for Health Professionals

Reported Prevalence of Maternal Hepatitis C Virus Infection in the United States

SMFM Consult Series #56: Hepatitis C in pregnancy—updated guidelines

Related ObG Topics:

STI Screening in Pregnancy: CDC Recommendations

Screening for Sexually Transmitted Infections – Who, When and How Often?

Is it Time for Universal Prenatal Hepatitis C Screening?

SMFM Releases Guidelines on Screening and Management of Hepatitis C in Pregnancy