Dr. Jordan Feld (left) and Dr. Hemant Shah
TGH liver specialists Dr. Jordan Feld (left) and Dr. Hemant Shah discuss revised Canadian guidelines to screen all baby boomers for hepatitis C. (Photo: UHN)

The opioid crisis, aging baby boomers, and new curable treatments for hepatitis C infection compel Canada to revise and widen its screening for hepatitis C to include all baby boomers, as well as those most at risk, say liver specialists from the Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network.

Unlike other chronic viral infections, hepatitis C is curable.

In an article published today in the Canadian Medical Association Journal (CMAJ), co-lead authors Drs. Hemant Shah and Jordan Feld present arguments and data in favour of developing and implementing a national screening program for hepatitis C in Canada, with specific links to care and treatment for marginalized and rural and remote populations. They discuss this work in a CMAJ podcast.

Simplified treatment regimens, the continuing high burden of hepatitis C, substantial costs to the system, and the World Health's Organization call to eliminate viral hepatitis as a major public health threat by 2030, have spurred experts from across Canada to come together to revise earlier Canadian guidelines. The guideline now suggests screening all those born from 1945-1975, as well as those most at risk.

The new guidelines for specialists, primary care physicians, nurses and other healthcare professionals also make recommendations about screening, testing, pre-treatment work-ups, treatment, training of primary care providers to widen access to treatment, and the use of telemedicine to co-manage long-distance patients.

"Baby boomers are much more likely to be infected with hepatitis C than other age groups," says Dr. Jordan Feld, a liver specialist in Toronto General Hospital.

"Most people who have the infection have no or very few symptoms even if they've been infected for decades. Without symptoms, many infected people have no idea they have the disease until it's too late."

It is estimated more than 245,000 persons are living with chronic hepatitis C in Canada - more than half of them baby boomers. Moreover, estimates suggest that between 45 to 70 per cent of hepatitis C-infected Canadians remain undiagnosed.

"Now is the time to consider a national screening strategy. This silent epidemic can be turned around and many more lives could be saved with a coordinated approach," emphasizes Dr. Feld, who is also Associate Professor of Medicine at the University of Toronto and Research Director at the Toronto Centre for Liver Disease.

"Baby boomer screening, improved access to treatment, increased uptake of treatment by non-specialist healthcare providers, and a major education campaign could reverse the alarming trends we are seeing caused by hepatitis C today."

"Hepatitis C has the greatest impact of all infectious disease in Ontario, even more so than HIV, influenza virus or human papillomavirus," adds Dr. Hemant Shah, Clinical Practice Director of the Toronto Centre for Liver Disease.

"It's a life-changing diagnosis, yet there is a huge gap in public and healthcare provider awareness about the disease, it's implications, and the treatment options for patients."

Treating early

Hepatitis C causes more years of life lost than any other infectious disease in Ontario, and likely in Canada, and is the leading indication for liver transplantation. The virus slowly destroys the liver over many years of infection eventually leading to cirrhosis and ultimately liver failure or liver cancer.

However, if hepatitis C is diagnosed early, it is curable. New antiviral agents eradicate hepatitis C virus from the blood in as little as eight to 12 weeks and have few or no side effects – a major improvement over previous treatments.

Once liver disease is very advanced, treatment is less effective and may not be possible, so the goal is to find people with hepatitis C before the virus has caused liver damage. Screening for hepatitis C involves a simple blood test, which is covered by all provincial healthcare plans.

Currently, the recommended Canadian approach is to test based on risk factors. These include:

  • injection drug use (even once)
  • receiving blood transfusions or blood products before 1992
  • piercings or tattoos done in an unclean environment with unsterile equipment
  • exposure to infected blood through sharing personal care items such as razors, toothbrushes
  • being immunized or receiving a medical procedure in countries where hepatitis C is common

The authors point out risk-factor based screening has not been successful in Canada or other countries, including the U.S. and Europe. Primary care physicians and those infected are often unaware of risk factors, individuals may be uncomfortable talking about high-risk behaviours, and up to 30 per cent of infected individuals have no identifiable risk factors, and would therefore be missed. Most studies show that risk factor based screening does not work for hepatitis C and most other chronic infections.

In contrast, the Centers for Disease Control and Prevention (CDC) in the U.S. has recommended screening all individuals born between 1945 and 1965 for hepatitis C virus. Even though most baby boomers do not have the infection, the CDC adopted the policy because they have shown that identifying infected people and treating them early will save lives and money by avoiding the costs associated with complications of liver disease.

If nothing is done to ensure treatment, say the authors, liver-related deaths will increase by 160 per cent by 2035. In addition, annual costs linked to chronic hepatitis C (not including antiviral therapies) are expected to rise from an estimated $161 million in 2013 to more than $258 million in 2032.

Eliminating hepatitis C by 2030 is doable for the first time because we have the tools, says Dr. Shah, who is an Assistant Professor in Medicine, University of Toronto.

"We have the therapies, the know-how, the knowledge of what it would take to achieve this," he says.

"But we need a coordinated, national strategy on screening, early testing and treatment, along with harm-reduction intervention to reduce new infections and reinfections, such as those from opioid misuse."

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