Under the joint leadership of the Vatche and Tamar Manoukian Division of Digestive Diseases and the Division of Infectious Diseases, UCLA Health has embarked on a major initiative to screen baby boomers for the hepatitis C virus (HCV). The initiative is based on the recommendation of the U.S. Preventive Services Task Force that in addition to screening all adults at high risk for the infection - including anyone who has ever injected drugs or used intranasal cocaine, patients who have been on hemodialysis, and those who received transfusions or organ transplants before 1992 - baby boomers undergo a one-time screening. Approximately three-fourths of patients in the United States living with HCV infection were born between 1945 and 1965.
Hepatitis C infection is a leading cause of complications from chronic liver disease in the United States. It is the most common cause of cirrhosis, the biggest risk factor for liver cancer, and the most common indication for liver transplantation. Nationally, hepatitis C-related end-stage liver disease accounts for more than 30 percent of liver transplant indications among adults. At UCLA, more than half of the liver-transplant patients developed liver failure as a result of hepatitis C. Particularly alarming is that of the estimated 5 million people in the U.S. who are HCV-positive - four times the number believed to be infected with HIV - about three-fourths don't know it, because the infection rarely causes symptoms until the patient has developed chronic liver disease, a process that can take decades. "This is a major public health concern," says Sammy Saab, MD, MPH, a hepatologist and associate professor in the Vatche and Tamar Manoukian Division of Digestive Diseases. "People with hepatitis C don't wear a badge saying that they're infected. Most are completely asymptomatic, and the only way they can be diagnosed is through a routine blood test by their health care provider."
Identifying HCV-positive individuals has become all the more important over the last year with the advent of antiviral therapy that represents a major improvement over prior treatment. "Previously, people had to have weekly immune-therapy injections for up to a year, and it was very debilitating - causing headaches, fevers, and even depression," says Jeffrey D. Klausner, MD, MPH, professor in the Division of Infectious Diseases. "Now, we have oral medications that are very well tolerated and far more effective. The vast majority of patients who complete the course - typically three months, but sometimes as short as two months - are cured."
Dr. Saab adds that the medical community has undergone an evolution in the way it views HCV infection, leading to broader indications for treatment. "We used to be fixated with the idea that hepatitis C causes liver disease, and now we know that it is a systemic infection that can affect not only the liver, but other parts of the body as well," he says. "There are many conditions associated with hepatitis C that we are beginning to appreciate, and as a result, we recognize that everyone with the virus should be treated to prevent these complications, not just patients with liver disease damage."
Baby boomers are a particularly important group to screen because many from that age group who are infected have had the virus for a long period of time, putting them at high risk for developing the complications of liver cirrhosis, liver cancer and liver failure, Dr. Saab notes. "We have this new treatments that is are safe, rarely cause side effects, and can cure patients," he says. "If we wait until they become symptomatic, it's often too late to treat hepatitis C." The UCLA HCV screening initiative, under the leadership of Drs. Saab and Klausner through the digestive diseases and infectious diseases divisions, is a multi-layered effort that started with educating UCLA Health's primary care program leaders on the importance of hepatitis C screening and the national recommendations. Next, a reminder was introduced into CareConnect, UCLA's electronic health record, so that when primary care physicians see individuals born between 1945 and 1965 who haven't yet been screened, they are alerted that the patient should be tested for the virus.
Patients who test negative do not need to be tested again, assuming they don't meet any of the other high-risk criteria. When a patient tests positive, the ordering physician receives a notification, along with recommendations for additional tests to confirm the infection and assess the degree of liver damage. A dedicated hepatitis C treatment coordinator monitors the laboratory results and provides assistance to link the providers with hepatologists and infectious disease specialists in the Vatche and Tamar Manoukian Division of Digestive Diseases and Division of Infectious Diseases so that patients can receive timely and appropriate care.
To further expedite the process, the new initiative has instituted automated viral load testing and genotyping for anyone testing positive, so that patients don't have to return for a second blood draw. The results of those tests help to guide treatment decisions. Dr. Klausner believes the collaborative initiative - which, in addition to the digestive diseases and infectious diseases divisions, involves UCLA's Department of Pathology & Laboratory Medicine and the CareConnect program - can serve as a model for nationwide efforts to detect, treat and cure HCV infection. The UCLA team is evaluating the results of the initiative and will be sharing its findings with other institutions. Already, the program has resulted in a threefold increase in the number of patients being screened. "As one of the country's leading health systems, it is incumbent on us to identify patients who have a curable disease like hepatitis C," Dr. Klausner says. "Our intention is to play a leadership role in promoting cost-effective interventions that prioritize prevention." "Hepatitis C is a major cause of liver disease, and now we can prevent these complications through early treatment," adds Dr. Saab. "The biggest barrier to curing hepatitis C is knowing who is infected. That's why this initiative is so critical."
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