Hepatitis C screening now recommended for Canadian baby boomers

In 2001, Sherry Hughes went for a routine physical exam that changed her life forever.

A test showed elevated liver enzymes, leading her doctor to order another test. It turned out that Hughes had hepatitis C. She was told that the virus had done serious damage to her liver.

“It was a big shock because I don’t have any of the markers for someone who would typically contract hepatitis C,” says Hughes, who lives in Brampton, Ont.

Hughes, who was 57 at the time of her diagnosis, says she had never been an intravenous drug user, had no tattoos and had not received had any blood transfusions – all considered common risk factors.

“I didn’t know where I had got it, so that was a bit of a concern,” she adds. “I had been a normal, healthy, fit kind of individual up until that point.”

Hughes is not the only Canadian who has received a surprise chronic hepatitis C diagnosis. It’s estimated that more than 250,000 people live with the disease in Canada and most don’t know that they have it.

As a result, liver specialists are now urging a blood test for all Canadians born between 1945 and 1975 to screen for the virus.

Hepatitis C is a “highly burdensome public health problem in Canada, which actually causes more years of life lost than any other infectious disease in the country,” said the authors from the Canadian Association for the Study of the Liver. Their recommendations were published Monday in the Canadian Medical Association Journal (CMAJ).

Thanks to new medicines, hepatitis C is now relatively easy to cure. After more than a decade of unsuccessful treatments, Hughes was given the all-clear in 2016 thanks to a 12-week course of the drug Harvoni (Ledipasvir/sofosbuvir).

Part of the problem, doctors say, is that the disease is slow moving and often doesn’t present symptoms until serious liver damage or disease has already occurred.

“You can carry this infection for decades in your liver and actually have no symptoms at all -- You can feel perfectly well," Dr. Hemant Shah told CTV News Channel. "The symptoms typically develop at the very, very end stages of the disease when people develop liver failure, liver cancer, or need a liver transplant.”

Current clinical practice guidelines call for screening only for those at risk but physicians say risk factors can be difficult to identify and that multiple and rapid advances in the field, including much more effective and lower-cost drug therapies, require changes to treatment practices.

“Between 45 per cent and 70 per cent of Canadians infected with HCV are unaware they have the disease, which can lead to liver disease and death. It seems evident that the current policy of screening based on risk factors has not worked," say the authors of the new CMAJ recommendations.

The researchers estimate between two-thirds and three-quarters of those living with HCV in Canada were born from 1945 to 1975 and that 1.6 per cent of those in that cohort has HCV.

“There is a dramatic under-recognition of how prevalent hepatitis C is in Canada and how much it contributes to illness and healthcare costs,” Shah told CTVNews.ca in an interview. “And that’s not just the public, but among healthcare professionals, too.”

He said age-triggered screening is well-established for other health threats, including breast cancer, cholesterol and colon cancer, and that treatments for hepatitis C that will prevent cirrhosis, failure and cancer down the road are “incredibly effective.”

“More than 95 per cent of infected people can be reliably cured with antiviral drug therapies. That can’t even be achieved by antibiotics for common illnesses,” he said.

Shah, an assistant professor of medicine at the University of Toronto and clinical director at the Toronto Centre for Liver Disease, says early baby boomers may have been infected in the 1970s or 1980s, during a first epidemic of hepatitis C infection.

“They were presenting to hospitals with liver failure or liver cancer in their 40s or 50s.”

We are now in a second epidemic of infection, he says, due to the opioid crisis.

Linking screening to age “is a simple way to approach screening, rather than trying to address risk factors, which people may not be aware of (or) may not be comfortable disclosing,” co-author Dr. Jordan Feld said in a CMAJ podcast.  

The Canadian Task Force on Preventive Health Care recommended in April 2017 against screening people who are not at high risk of infection but the liver researchers disagree, saying that group overvalued the costs of therapy and undervalued the benefits of curative treatment.

“The challenge is we’re not very good at recognizing who’s at low risk,” said Feld, an associate professor of medicine at the University of Toronto and clinician-scientist and research director at the Toronto Centre for Liver Disease. “We’ve had a policy of using so-called risk-based screening for many years now and unfortunately, the most recent data in Canada would suggest that our diagnosis rate is very low.

Many people who become infected with hepatitis C never feel sick and recover completely, according to the Canadian Liver Foundation. Others get a brief, acute illness with fatigue and loss of appetite and their skin and eyes turn yellow or jaundiced. For those unable to fight off the virus (about 75 per cent of people who contract HCV), it may lead to chronic hepatitis which, in about a quarter of cases, can cause cirrhosis (liver scarring), liver failure and liver cancer later in life.

Though the human body produces antibodies to HCV, the virus changes too rapidly for them to be effective. There is no vaccine.

Hepatitis C is spread through hepatitis C-infected blood entering another person’s blood stream. According to the CLF, a person risks exposure to hepatitis C by using injection drugs (even once), getting tattoos, piercings, pedicures, manicures or medical procedures with improperly sterilized equipment, sharing personal hygiene items with an infected person (such as razors, toothbrushes, nail clippers), certain unsafe sex practices, or having had a blood transfusion or receiving blood products prior to July 1990.

Others considered at high risk include those who have been in jail or who have “been injected or scratched during vaccination, surgery, blood transfusion or a religious/ceremonial ritual in regions where hepatitis C is common.” Hepatitis C is common in many parts of the world and the World Health Organisation has set targets to eliminate it as a public health threat by 2030.