USPSTF Recommends Universal Screening for Hepatitis C
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
The same regimens recommended for chronic HCV infections are recommended for acute infection
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)
Otherconsiderations
Advise abstinence from alcohol and acetaminophen during acute infection
Evaluate for hepatitis B and HIV infection
Vaccinate against Hepatitis A and Hepatitis B
Evaluation for advanced hepatic fibrosis with
Elastography or liver imaging (US or CT Scan)
FIB-4 Score (see ‘Learn More – Primary Sources’ below for calculator)
Lab tests: ALT | AST | Albumin | Bilirubin | INR | CBC
Provide education on how to prevent HCV transmission to others
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
Pregnant women are considered a ‘special population’ by the CDC. Due to the potential burden to pregnant women, offspring and partners, providers should ask all pregnant women and their partners about STIs, and ensure counseling, screening and treatment are available.
Rapid HIV testing should be performed on any woman in labor who has not been screened during pregnancy, unless she declines
If rapid HIV test positive, antiretroviral prophylaxis should be administered prior to receiving confirmatory test results
AAP recommends expedited HIV testing as soon as possible after birth for infants born to women with unknown HIV status
NOTE: The USPSTF (June 2019) continues to recommend screening for HIV infection in all pregnant persons, including those who present in labor or at delivery whose HIV status is unknown. (A recommendation)
SYPHILIS
Cases of congenital syphilis have increased 10 fold in the past decade
Syphilis during pregnancy can lead to
Stillbirth | Miscarriage | Infant death | Maternal and infant morbidity
Serologic tests should be performed at first prenatal visit
Screening for syphilis infection is a 2-step process | Antepartum screening can be performed by manual nontreponemal antibody testing (e.g., RPR) by using the traditional syphilis screening algorithm or by treponemal antibody testing (e.g., immunoassays)
Traditional screening
Initial “nontreponemal” antibody test (ie, Venereal Disease Research Laboratory test or rapid plasma reagin [RPR] test) to detect biomarkers released from damage caused by syphilis infection
Followed by a confirmatory “treponemal” antibody detection test (ie, fluorescent treponemal antibody absorption [FTA-ABS] or T pallidum particle agglutination test [TP-PA])
Reverse sequence screening algorithm
Initial automated treponemal test (such as an enzyme-linked [EIA], chemiluminescence [CIA], or multiplex flow immunoassay [immunoblot])
Followed by a nontreponemal test
NOTE: If the test results of the reverse sequence algorithm are discordant, a second treponemal test (preferably using a different treponemal antibody) is performed
Pregnant women with positive treponemal screening tests (e.g., EIA, CIA, or immunoblot) should have additional quantitative nontreponemal testing because titers are essential for monitoring treatment response
If access to prenatal care is suboptimal, RPR test and treatment should be performed at time of pregnancy confirmation
Serologic retesting in the 3rd trimester (28 weeks) and at delivery if the patient for patients at high risk including
Sex with multiple partners | Sex in conjunction with drug use or transactional sex
Late entry to prenatal care (i.e., first visit during the second trimester or later) or no prenatal care
Methamphetamine or heroin use
Incarceration of the woman or her partner
Unstable housing or homelessness
Test any woman who delivers a stillborn or in the case of infant death
Untreated syphilis has a 40% infant death rate
Do NOT discharge neonate if serologic status is unknown
Newborn infection may not be immediately obvious
Within a few weeks may develop
Developmental delay
Seizures
Birth defects such as bone deformation, blindness and deafness
Note: In September 2018, the USPSTF reaffirmed previous guidance and “recommends early screening for syphilis infection in all pregnant women.” (Grade A – Offer or Provide this Service)
HEPATITIS B (HBV)
Screen during each pregnancy, preferably in the first trimester, regardless of vaccination status or history of testing
Use ‘triple panel’: Hepatitis B surface antigen (HBsAg), antibody to HBsAg, and total antibody to HBcAg (total anti-HBc)
If patient underwent appropriately timed triple panel screening and has not had any new HBV exposures since triple panel screening, only HBsAg screening is required
At time of admission for delivery, retest if patient
Is at high risk – more than one sex partner in previous 6 months, evaluation or treatment for STI, injection-drug use, HBsAG-positive sex partner
Was not screened prenatally
Has clinical hepatitis
Always do HBsAg testing prior to giving the HBV vaccine to avoid misinterpretation
Report HBsAg positive women to local or state health departments to ensure they are entered into a case management program to arrange access to appropriate vaccinations for contacts and prophylaxis for infants
If HBsAg positive, test for hepatitis B virus deoxyribonucleic acid (HBV DNA) to guide the use of antiviral medication to prevent perinatal transmission
If HBV DNA >200,000 IU/mL (7.6 log10 IU/mL): The American Association for the Study of Liver Diseases suggests antiviral therapy during pregnancy to further reduce perinatal HBV transmission
HEPATITIS C (HCV)
The CDC has updated HepC guidelines (2020)
Hepatitis C screening at least once in a lifetime for all adults aged ≥18 years, except in settings where the prevalence of HCV infection (HCV RNA-positivity) is <0.1%
Hepatitis C screening for all pregnant women during each pregnancy, except in settings where the prevalence of HCV infection (HCV RNA-positivity) is <0.1%
USPSTF also calls for universal screening for HCV infection, including pregnancy
Recommended Screening Tests for Pregnant Women at Risk
CHLAMYDIA
Test all pregnant women who are <25 years old for Chlamydia trachomatis at the first prenatal visit
Test all older women if at high risk:
More than one sex partner
A sex partner with concurrent partners or has an STI
Retest in the 3rd trimester to prevent maternal postnatal complications and chlamydia infection in the neonate
Test of cure by NAAT 3 to 4 weeks after treatment and retest within 3 months
GONORRHEA
Test all pregnant women who are <25 years old for N. gonorrhoeae at the first prenatal visit
Test all older women if at high risk:
More than one sex partner
A sex partner with concurrent partners or has an STI
Inconsistent condom use in non-monogamous relationships
Previous or co-existing sexually transmitted infections
Exchanging sex for money or drugs
Consider consulting local public health authorities for further guidance on identifying those at high risk related to geographic location
Treat all positive patients immediately and retest in 3 months
Retest in the 3rd trimester to prevent maternal postnatal complications and chlamydia infection in the neonate
Screen Only if Symptomatic
Bacterial Vaginosis (BV)
Evidence does not support routine screening
Evaluate and screen symptomatic women
The USPSTF addresses BV screening during pregnancy and states the following
The USPSTF addresses BV screening during pregnancy and states the following The USPSTF recommends against screening for bacterial vaginosis in pregnant persons not at increased risk for preterm delivery. (D recommendation)
The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for bacterial vaginosis in pregnant persons at increased risk for preterm delivery. (I statement)
Trichomonas
Evidence does not support routine screening
Evaluate and screen symptomatic women
HSV-2
Evidence does not support routine screening
In the absence of lesions during the 3rd trimester, routine cultures for HSV are not indicated for women in the 3rd trimester who have a history of recurrent genital herpes
Type-specific serologic tests may help identify pregnant women at risk for HSV and to help guide counseling regarding the risk of acquiring herpes during pregnancy
SYNOPSIS:
Recommendations for STI testing can vary based on certain considerations, including state laws. The CDC recommendations are considered broader, such that more women will potentially be screened, but are consistent with other CDC guidance with the intention of preventing adverse outcomes for pregnant women, partners and fetuses.
KEY POINTS:
All pregnant women and their partners should be asked about STIs and counseled regarding personal risks as well as pregnancy and outcomes
Pap Smears should be performed in pregnancy at the same frequency as nonpregnant women
Management of abnormal Pap tests differ in pregnancy
Screening at Delivery
SYPHILIS
Select groups of pregnant women, including women who are at high risk for syphilis or live in areas of high syphilis morbidity
Pregnant women with no previously established status
Pregnant women who deliver a stillborn infant
HIV
Pregnant women not screened during pregnancy
HBV
Women admitted for delivery at a health care facility without documentation of HBsAg test results should have blood drawn and tested as soon as possible after admission
Women at high risk
Having had more than one sex partner during the previous 6 months, an HBsAg-positive sex partner, evaluation or treatment for a sexually transmitted disease, or recent or current injection-drug use
Women with signs or symptoms of hepatitis
Note: CDC recommends universal hepatitis B vaccination within 24 hours of birth for medically stable infants >2000 grams
Permissive language that allowed the vaccine to be delayed until after hospital discharge has been removed
Administer hepatitis B vaccination and hepatitis immune globulin regardless of birth weight within 12 hours of birth for infants born to hepatitis b-infected mothers
CHLAMYDIA
Pregnant women less than 25 years of age
Continued high risk
New or multiple sex partners, sex partner with concurrent partners, sex partners who have a sexually transmitted disease
GONORRHEA
Continued high risk
Past or current injection-drug use, having had a blood transfusion before July 1992, receipt of an unregulated tattoo, having been on long-term hemodialysis, intranasal drug use, and other percutaneous exposures
Screening for Sexually Transmitted Infections – Who, When and How Often?
SYNOPSIS:
There are an estimated 2.8 million new chlamydia infections each year in the US and 1.5 million new cases of gonorrhea diagnosed. The highest rates of both gonorrhea and chlamydia are reported in women aged 15 to 24. Symptoms are vague and sequelae can include pelvic inflammatory disease, ectopic pregnancy and infertility. A full comprehensive sexual history may identify other risk factors to prompt more comprehensive screening for sexually transmitted infections
CLINICAL ACTIONS:
Sexually transmitted infections (STIs) are common with potential for serious long term outcomes, and remain a serious public health concern. Here, we outline the recommendations for screening for STIs by population:
General Population
Gonorrhea and Chlamydia
Annual screening for gonorrhea and chlamydia is recommended for all sexually active women <25 years | evidence is insufficient for routine testing of gonorrhea and chlamydia in heterosexual men, consider screening young men in high prevalence clinical settings e.g. adolescent clinics, correctional facilities, STI/sexual health clinic
Re-testing is recommended 3 months after treatment due to high re-infection rates
Screening is recommended for adults >25 years old at increased risk for infection (new partner, multiple partners, or a partner who has an STI)
Consider testing for rectal chlamydia and pharyngeal gonorrhea based on sexual history practices
Annual testing is recommended for men who have sex with men (MSM) at sites of contact (urethra, rectum)and every 3-6 months if at higher risk e.g. MSM on PrEP, HIV infection, or if they or their sex partners have multiple partners
Transgender and Gender Diverse Persons screening adapted based on anatomy
Syphilis
Screening for syphilis is based on risk profile, with higher risk including history of incarceration, transactional sex work, geography, or male younger than 29 years old
Annual screening for sexually active MSM | 3 to 6 months if at increased risk
Annual screening for syphilis is recommended in transgender and gender diverse persons
HIV
Screening for HIV should be performed in all adults aged 13 to 64 and who seek evaluation and treatment for STIs | Annual HIV screening is recommended for MSM with more than one sexual partner, with consideration for more frequent 3-6 month intervals for testing
HSV
Consider type-specific HSV serologic testing in patients presenting for an STI evaluation (especially if multiple partners) | Note: USPSTF “recommends against routine serologic screening for genital HSV infection in asymptomatic adolescents and adults, including those who are pregnant”
Trichomonas
Consider screening for trichomonas in high-prevalence settings or patients at higher risk for infection (multiple sex partners, transactional sex, drug misuse, or a history of STI or incarceration)
Hepatitis B
Screen all adults aged ≥18 years at least once during a lifetime (CDC recommendation)
Use triple Panel: 3 main serologic markers used to determine HBV infection status
Hepatitis B surface antigen (HBsAg) | Antibody to hepatitis B surface antigen (anti-HBs) | Antibody to hepatitis B core antigen (anti-HBc)
Test individuals with a history of risk for HBV infection, regardless of age, if they might have been susceptible during the period of risk
Susceptible persons include those who have never been infected with HBV (i.e., total anti-HBc negative) and either did not complete a HepB vaccine series per ACIP recommendations or who are known vaccine nonresponders
Periodically test susceptible persons, regardless of age, who have ongoing risk | Offer testing if the risk for exposure occurred after previous HBV serologic testing and while the person was susceptible
Offer testing to anyone who requests HBV testing
Hepatitis C
Screening for hepatitis C infection (HCV) should take include all adults over age 18 years except in settings with HCV positivity < 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
Persons living with HIV
At first HIV evaluation and annually afterwards, screen for
Gonorrhea
Chlamydia
Syphilis
Hepatitis B surface antigen and Hepatitis B immunity
Hepatitis C screening for all persons with HIV and subsequent annual testing for MSM
Specifically for women with HIV
Screen for trichomonas for women at first evaluation and annually afterwards
Women should be screened within 1 year of sexual activity with testing repeat 65 months later | 3 normal and consecutive pap tests, screening can be spaced out to every 3 years
The USPSTF 2021 update
…recommends screening for chlamydia in all sexually active women 24 years or younger and in women 25 years or older who are at increased risk for infection. (B recommendation)
…recommends screening for gonorrhea in all sexually active women 24 years or younger and in women 25 years or older who are at increased risk for infection. (B recommendation)
The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for chlamydia and gonorrhea in men
KEY POINTS:
Screen sexually active women ≥25 for gonorrhea and chlamydia if at increased risk
More comprehensive screening for STIs include evaluation for trichomonas, syphilis, HIV, Hepatitis B and Hepatitis C
CDC has updated guidelines to recommend universal Hepatitis C and Hepatitis B screening in all adults
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