Monday, April 24, 2017

New hepatitis C screening guidelines will lead to avoidable deaths and soaring costs to health care system

New hepatitis C screening guidelines will lead to avoidable deaths and soaring costs to health care system

Reliance on risk-based testing will perpetuate low diagnosis rates and increases in cirrhosis and liver cancer 

Toronto, April 24, 2017: They may not look sick. They may not feel sick. And yet many Canadians in the prime of their lives are living with a potentially fatal liver disease -- hepatitis C. An estimated 44 percent of Canadians with hepatitis C have no idea that they have it. Unfortunately, the Canadian Task Force on Preventive Health Care’s  (CTFPHC) new screening guidelines released today recommend against screening of adults without identifiable risk factors which may result in the bulk of the age group most at risk of having chronic hepatitis C (those born between 1945 and 1975) remaining undiagnosed.

“Liver cancer rates are rising in Canada due in large part to late diagnosis and lack of treatment of hepatitis C,” says Dr. Morris Sherman, Chairperson of the Canadian Liver Foundation and a practicing hepatologist. “While we congratulate CTFPHC’s commitment to hepatitis C testing, the truth is that risk-based testing, which was first recommended in 2009  has only been effective in identifying a small proportion of adults with recognized risk factors. If you or your doctor don’t think you have any risk factors then according to these guidelines you won’t be tested.  We are disappointed that, despite widespread support among medical experts and advocacy groups, the CTFPHC failed to establish new  guidelines which would encourage widespread screening not just based on risk factors but also by age.”

In August 2012, the U.S. Centers for Disease Control and Prevention issued its recommendation that all adults born between 1945 and 1965 should have a one-time hepatitis C test. Based on the prevalence data in Canada and taking into account immigration from countries where hepatitis C is endemic, the Canadian Liver Foundation believed the age bracket should be expanded and issued its own recommendations that same year that adults born between 1945 and 1975 be tested. In 2013, the Public Health Agency of Canada (PHAC) began reviewing its screening guidelines for hepatitis C, but no new guidelines were issued. Subsequently, PHAC tasked the CTFPHC with reviewing evidence and coming up with recommendations.

The new CTFPHC guidelines call for screening of adults with known risk factors including blood transfusions prior to 1992, past or present injection drug use, and coming from certain countries where hepatitis C is endemic. The  guidelines strongly recommend against screening for those without recognized risk factors meaning that if a person is not aware of a situation in which they may have been exposed to hepatitis C (i.e. from contaminated medical equipment, a common source of transmission in other countries) then they will not qualify for testing.

“The CTFPHC expressed concern over the costs of testing such a large group, the potential for false positives and the mental distress that a diagnosis might cause,” says Dr. Sherman. “But don’t we have an obligation to inform people if they have a potentially fatal but curable disease?”

Data suggests that age-based screening of adults born between 1945 and 1975 could capture as much as 77 percent of the population living with undiagnosed hepatitis C.1  Age-based screening is also cost-effective based on a reduction in deaths due to hepatitis C,  increases in quality of life years and savings in acute care costs for those with advanced disease.2  While the cost of treatment has previously been an obstacle, recent negotiations by the Pan-Canadian Pharmaceutical Alliance (pCPA) have successfully reduced the cost of several of the leading hepatitis C drug therapies.

“The CTFPHC guidelines wrongly assume that the majority of those with hepatitis C would only have early stage disease,” says Dr. Sherman, “when in fact most have been living with it for decades. They do not adequately acknowledge the tragic personal costs and the health system costs of these individuals being diagnosed only when they have progressed to cirrhosis, liver cancer or liver failure. They over-estimate the potential harms of screening and fail to recognize the potential harms of not screening – the missed opportunities to save lives and to save downstream costs  to the health care system for liver transplants and acute care for those suffering from advanced hepatitis C.”

In 2016, the federal Health Minister Dr. Jane Philpott publicly committed to the World Health Organization’s goal of eliminating hepatitis C by 2030. Canada’s dismal diagnosis rates are due in part to risk-based screening which has been in place for years. The CTFPHC’s  long-awaited screening guidelines maintain the status quo which will leave tens of thousands still undiagnosed. We therefore call upon Minister Philpott to ask CTFPHC to reconsider their guidelines or justify how the continued reliance on risk-based screening only will achieve her commitment to eliminate hepatitis C.

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