Impact and Cost-effectiveness Analysis of Screening Recommendations for Hepatitis C Virus Infection
- Hepatitis C virus (HCV) can cause a serious and sometimes fatal infection of the liver. However, 44% of persons living with chronic HCV infection do not know their HCV status.
- In 2012 CDC recommended one-time screening for persons born between 1945-1965 (baby boomers), but changes in treatment availability and the impact of the opioid crisis on younger generations have resulted in a need to evaluate hepatitis C screening trends, prevalence, and options for cost-effective strategies to move toward hepatitis C elimination.
- Several NEEMA projects addressed key information gaps and found:
- Following release of the screening recommendations for baby boomers in 2012, a 106% increase in screening rates among people born during 1945-1965 was observed by 2014.
- Approximately 2.4 million persons are living with chronic hepatitis C in the United States.
- Expanding screening recommendations to all persons ≥18 years results in an estimated 256,000 additional infected persons identified, 280,000 additional cures, and 4,400 fewer cases of hepatocellular carcinoma with an incremental cost-effectiveness ratio of $28,000 per quality adjusted life year gained.
- These studies illustrate the effect CDC recommendations have and can have on increasing testing among target populations, provide updated information for programs on the number of persons living with chronic hepatitis C , and inform new recommendations from CDC, U.S. Preventive Services Task Force (USPSTF), and Infectious Disease Society of America/American Association for the Study of Liver Disease (IDSA/AASLD) to screen for hepatitis C at least once in a lifetime for all adults aged ≥18 years.
Hepatitis C virus (HCV) can cause a serious and sometimes fatal infection of the liver. The virus is spread primarily when blood from an infected person enters the body of someone who is not infected. For some persons, HCV infection causes no symptoms, or only a mild illness that resolves over a few weeks. For the majority of infected persons, however, untreated HCV infection causes a serious, chronic illness. In the United States, 44% of persons living with chronic HCV infection do not know their HCV status.1 Without screening and diagnosis, these persons cannot take the first step toward lifesaving curative treatment. Without treatment, persons with chronic HCV infection can die prematurely. In 2018, approximately 16,000 persons died in the United States because of chronic HCV infection-related causes.2
Several NEEMA projects were supported to address key information gaps including assessing the change in screening rates for persons born between 1945-1965 following the 2012 change in CDC testing recommendations, updating the estimated number of persons living with chronic HCV infection, and modeling the population-level outcomes and cost-effectiveness of expanding the screening recommendations to a broader age range.
Assessing change in hepatitis C screening rates during 2010-20143
- This NEEMA project used an interrupted time series analysis with a comparison group design to look at hepatitis C screening rates in the period 2010-2014 among 2.8 million commercially insured adults in the MarketScan database.
- Hepatitis C screening rates increased yearly between 2010 and 2014, from 1.65 to 2.59 per 100 person-years. A 49% increase in screening rates among people born during 1945-1965 followed the release of the recommendations, resulting in a 106% increase by 2014.
Estimating prevalence of hepatitis C virus infection in the United States4
- This NEEMA project updated previous prevalence estimates by analyzing 2013-2016 data from the National Health and Nutrition Examination Survey to estimate the prevalence of HCV in the noninstitutionalized civilian population, and used a combination of literature reviews and population size estimation approaches to estimate the prevalence of HCV infection and population sizes for four additional populations: people who are incarcerated, people experiencing homelessness, active-duty military personnel, and nursing home residents.
- The study estimated that during 2013-2016, 1.7% of all adults in the United States, approximately 4.1 million persons, were HCV antibody-positive, indicating past or current infection, and 1.0% of all adults, approximately 2.4 million persons, were HCV RNA-positive, indicating current infection.
Population-level outcomes and cost-effectiveness of expanding screening recommendations5
- This NEEMA project used a simulation of HCV infection to estimate the effectiveness and cost-effectiveness of four different HCV testing strategies: (1) standard of care (SOC) – recommendation for one-time testing for all persons born 1945-1965, (2) recommendation for one-time testing for adults ≥40 years, (3) recommendation for one-time testing for adults ≥30 years, and (4) recommendation for one-time testing for adults ≥18 years.
- Expanded age-based testing strategies increased U.S. population lifetime case identification and cure rates. Greatest increases were observed in the ≥18 years strategy compared to SOC; this strategy resulted in an estimated 256,000 additional infected persons identified, 280,000 additional cures, and 4,400 fewer cases of hepatocellular carcinoma with an estimated incremental cost-effectiveness ratio of $28,000 per quality adjusted life year.
These NEEMA studies illustrate the effect CDC recommendations have and can have on increasing testing among target populations and on the potential for reducing viral hepatitis-related morbidity and mortality. These studies also provided updated information for programs on the estimated number of persons living with chronic hepatitis C infection and informed new recommendations from CDC, USPSTF, and IDSA/AASLD. In 2020, CDC recommended hepatitis C screening at least once in a lifetime for all adults aged ≥18 years, as well as for all pregnant persons during each pregnancy, except in settings where the prevalence of HCV infection is <0.1%.6 In addition, hepatitis C testing, regardless of age or setting prevalence, continues to be recommended for persons with recognized conditions or exposures.6 The USPSTF and IDSA/AASLD similarly updated their recommendations to screening adults at least once in a lifetime.7, 8
- Kim HS, Yang JD, El-Serag HB, Kanwal F. Awareness of chronic viral hepatitis in the United States: an update from the National Health and Nutrition Examination Survey. J Viral Hepat 2019;26:596–602.
- Centers for Disease Control and Prevention. Viral Hepatitis Surveillance – United States, 2018. https://www.cdc.gov/hepatitis/statistics/SurveillanceRpts.htm. Published July 2020. Accessed November 3, 2020.
- Hepatitis C testing increased among Baby Boomers following the 2012 change to CDC testing recommendations. Health Aff (Millwood) 2017;36(12):2142-2150. DOI: https://doi.org/10.1377/hlthaff.2017.0684.
- Hofmeister MG, Rosenthal EM, Barker LK, et al. Estimating prevalence of hepatitis C virus infection in the United States, 2013–2016. Hepatology 2019;69:1020–31. DOI: https://doi.org/10.1002/hep.30297
- Barocas JA, Tasillo A, Eftekhari Yazdi G, et al. Population-level outcomes and cost-effectiveness of expanding the recommendation for age-based hepatitis C testing in the United States. Clin Infect Dis 2018;67:549–56. DOI: https://doi.org/10.1093/cid/ciy098.
- Schillie S, Wester C, Osborne M, Wesolowski L, Ryerson AB. CDC Recommendations for Hepatitis C Screening Among Adults — United States, 2020. MMWR Recomm Rep 2020;69(No. RR-2):1–17. DOI: http://dx.doi.org/10.15585/mmwr.rr6902a1.
- United States Preventive Services Task Force. Final Recommendation Statement – Hepatitis C virus infection in adolescents and Adults: Screening. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/hepatitis-c-screening. Published March 2, 2020. Accessed February 2, 2021.
- Infectious Disease Society of America, American Association for the Study of Liver Diseases. HCV testing and linkage to care. https://www.hcvguidelines.org/evaluate/testing-and-linkage. Published August 27, 2020. Accessed February 2, 2021.