I am writing to ask your help with diagnosing and treating hepatitis C, an increasing cause of illness and death among New Yorkers. Across the nation, hepatitis C virus (HCV) now causes more deaths annually than HIV infection. Because new drug regimens can cure HCV with more success than in the past, we now have the opportunity to prevent cirrhosis, end-stage liver disease, liver cancer, and death from HCV in people with HCV infection.
An estimated 145,000 New Yorkers are currently infected with HCV. Many New Yorkers with HCV remain undiagnosed, and one-third of those with a positive HCV antibody test have not had a confirmatory HCV RNA test. Many people diagnosed with HCV also do not receive appropriate counseling, education, and vaccinations.
I urge you to incorporate the following into your routine practice:
1. Test all people born between 1945 and 1965 (ie, “baby boomers”) at least one time for HCV antibody, regardless of risk factors. CDC recently recommended that everyone born during this period be tested, because approximately 75% of all HCV cases occur in this group and many patients do not report risk factors.
2. Ask all patients about HCV risk factors, especially whether they have ever injected drugs, even if only once or in the remote past. Others at risk include6
• people with persistently elevated alanine aminotransferase (ALT) levels;
• recipients of clotting factor concentrates before 1987 or blood transfusions, blood components, or organ transplants before 1992;
• people who were notified that they received blood from a donor who later tested positive for HCV infection;
• people ever on long-term hemodialysis;
• people with HIV;
• children born to mothers with current HCV infection;
• health care workers and others who have had mucosal or percutaneous exposure to HCV-infected blood. If any patient reports at least one HCV risk factor, perform an HCV antibody test.
3. For patients who test positive for HCV antibody, order an HCV RNA test. Consider any patient with a positive HCV RNA test to have current HCV infection.
4. Counsel all patients with current HCV infection (ie, HCV RNA positive) about how to maintain liver health, including abstaining from alcohol.
5. Explain how to prevent secondary HCV transmission by taking precautions such as
• avoiding blood exposure during sexual contact;
• not sharing drug use, tattoo, or piercing equipment.
6. Offer hepatitis A and B vaccination to susceptible patients with current HCV infection.
7. Evaluate all patients with current HCV infection for treatment. With proper support, even people actively using drugs can be cured of HCV. We encourage all primary care physicians to learn how to treat HCV (Resources). If you cannot provide treatment directly, refer patients to facilities that can.
Exciting advances in HCV diagnosis and treatment have improved our ability to prevent HCV transmission and reduce serious complications in those already infected. We appreciate your help in making that happen.
Thomas Farley, MD, MPH
1. Ly KN, Xing J, Klevens RM, Jiles RB, Ward JW, Holmberg SD. The increasing burden of mortality from viral hepatitis in the United States between 1999 and 2007. Ann Intern Med. 2012;156(4):271-278.
2. New York City Department of Health and Mental Hygiene. Unpublished data, 2013.
3. McGibbon , Bornschlegel K, Balter S. Half a diagnosis: gap in confirming infection status among patients who test positive for hepatitis C antibody, New York City, April 2009-May 2011. Am J Med. In press.
4. Bornschlegel K, Crotty KJ, Sahl S, Balter S. Unmet needs among people reported with hepatitis C, New York City. J Public Health Manag Pract. 2011;17(4):E9-E17.
5. Smith BD, Morgan RL, Beckett GA, et al. Recommendations for the identification of chronic HCV infection among persons born 1945-1965.
MMWR Recomm Rep. 2012;61(RR-4):1-32. www.cdc.gov/mmwr/preview/mmwrhtml/rr6104a1.htm. Accessed March 11, 2013. Erratum in
MMWR Recomm Rep. 2012;61(43):886.
6. Centers for Disease Control and Prevention (CDC). Testing recommendations for chronic HCV infection. www.cdc.gov/hepatitis/HCV/ GuidelinesC.htm. Accessed March 11, 2013.
7. New York City Department of Health and Mental Hygiene. Hep C – The Facts. Accessed March 11, 2013.
8. Litwin AH, Harris KA Jr, Nahvi S, et al. Successful treatment of chronic hepatitis C with pegylated interferon in combination with ribavirin in a methadone maintenance treatment program. J Subst Abuse Treat. 2009;37(1):32-40.
9. Arora S, Thornton K, Murata G, et al. Outcomes of treatment for hepatitis C virus infection by primary care providers. N Engl J Med. 2011;364(23):2199-2207.
• American Association for the Study of Liver Diseases (AASLD) Practice Guidelines: www.aasld.org/practiceguidelines/pages/default.aspx
• Clinical Care Options – Hepatitis (Continuing Medical Education): www.clinicaloptions.com/Hepatitis.aspx
• CDC – Hepatitis C FAQs for Health Professionals: www.cdc.gov/hepatitis/HCV/HCVfaq.htm