In 1998, CDC expanded the interagency guidelines to provide recommendations for preventing transmission of HCV; identifying, counseling, and testing persons at risk for hepatitis C; and providing appropriate medical evaluation and management of persons with hepatitis C (6). The guidelines recommended testing on the basis of risk factors for HCV infection for persons who ever injected drugs and shared needles, syringes, or other drug preparation equipment, including those who injected once or a few times many years ago and do not consider themselves as drug users; with selected medical conditions, including those who received clotting factor concentrates produced before 1987; who were ever on chronic hemodialysis (maintenance hemodialysis); with persistently abnormal ALT levels; who were prior recipients of transfusions or organ transplants, including those who were notified that they received blood from a donor who later tested positive for HCV infection; who received a transfusion of blood or blood components before July 1992, or who received an organ transplant before July 1992; and with a recognized exposure, including health care, emergency medical, and public safety workers after a needlestick injury, sharps injury, or mucosal exposure to blood infected with hepatitis C or children born to mothers infected with hepatitis C (6). In 1999, the U.S. Public Health Service and Infectious Diseases Society of America (IDSA) guidelines recommended hepatitis C testing for persons with HIV (36).
CDC determined that the new recommendations constituted scientific information that will have a clear and substantial impact on important public policies and private sector decisions. Therefore, the Information Quality Act required peer review by specialists in the field who were not involved in the development of these recommendations. CDC solicited nominations for reviewers from the American Association for the Study of Liver Diseases (AASLD), IDSA, and the American College of Obstetricians and Gynecologists (ACOG). Six clinicians with expertise in hepatology, gastroenterology, internal medicine, infectious diseases and/or obstetrics and gynecology provided structured peer reviews. In addition, feedback from the public was solicited through a Federal Register notice released on October 28, 2019, announcing the availability of the draft recommendations for public comment through December 27, 2019. CDC received 69 public comments on the draft document from academia, professional organizations, industry, and the public. Many of the comments from both peer reviewers and the public were in support of the recommendations. For those comments that proposed changes, the majority related to screening for hepatitis C in every pregnancy or removing the prevalence threshold for universal screening. Feedback attained during both the peer review process and the public comment period was reviewed by CDC. Ultimately, no changes to the recommendations were made; however, additional references and justification for the recommendation to screen during every pregnancy and maintaining the prevalence threshold were added to the document.
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Titles/abstracts for the all-adult review were independently reviewed by two reviewers, one of whom was always a senior abstractor (and author LW or SS). Conflicts were resolved by SS. If a conflict arose from a study whose title/abstract was reviewed only by both LW and SS, that study was retrieved for the full text review. All full texts were screened by both MO and LW. SS made the final decision regarding conflicts. Information from the full texts was extracted for the evidence review. A systematic review software program (Covidence; Melbourne, Victoria, Australia) was used to facilitate the all-adult review process.
Studies were excluded if they were conducted in a correctional facility because separate CDC guidance for hepatitis C screening in correctional facilities is under development. Other reasons for exclusion were: if prevalence data from 2010 forward could not be abstracted (all-adult review only); if the study reported estimated, projected, or self-reported data; if data were only available from a conference abstract, or if the study population was non-U.S. based, unless the study examined outcomes related to harms of screening. Studies related to harms of screening were included broadly to help ensure all potential harms were captured in the review. When multiple studies reported data for the same patients (e.g., when results of an initial pilot study were reported or when multiple studies reported outcomes of the CDC-funded Hepatitis Testing and Linkage to Care Project) (47), only the study with the most complete data was included. Linkage-to-care data were abstracted from 2010 forward from studies formally assessing linkage-to-care and reporting arrangement of or attendance at a follow-up appointment with a provider with special training for hepatitis C management. HCV RNA testing alone was not deemed linkage-to-care for purposes of this review, and studies did not have to report achievement of SVR to be included in the linkage-to-care review. Study design and setting were abstracted for all applicable studies. After the formal literature review was conducted, relevant studies identified through reference lists and those that were newly published were added for review.
The goal of hepatitis C screening is to identify persons who are currently infected with HCV. Hepatitis C testing should be initiated with a U.S. Food and Drug Administration (FDA)-approved anti-HCV test. Persons who test anti-HCV positive are either currently infected or had past infection that has resolved naturally or with treatment. Immunocompetent persons without hepatitis C risks who test anti-HCV negative are not infected and require no further testing. Persons testing anti-HCV positive should have follow-up testing with an FDA-approved nucleic acid test (NAT) for detection of HCV RNA. NAT for HCV RNA detection determines viremia and current HCV infection. Persons who test anti-HCV positive but HCV RNA negative do not have current HCV infection. CDC encourages use of reflex HCV RNA testing, in which specimens testing anti-HCV positive undergo HCV RNA testing immediately and automatically in the laboratory, using the same sample from which the anti-HCV test was conducted. Hepatitis C testing should be provided on-site when feasible.
In the absence of existing data for hepatitis C prevalence, health care providers should initiate universal hepatitis C screening until they establish that the prevalence of HCV RNA positivity in their population is
Persons with positive anti-HCV and positive HCV RNA test results should be informed that they have active HCV infection and would benefit from curative treatment. They will need further evaluation before treatment, medical care for possible liver disease, and ongoing medical monitoring. Persons with HCV infection should be provided information about treatment options, how to prevent transmission of HCV to others, and drug treatment, as appropriate. Persons with hepatitis C also should be informed about the resources available to them within their communities, including providers of medical evaluation, harm reduction, and social support.
Data informing the optimal time during pregnancy for hepatitis C testing are lacking. If DAA treatment becomes available for use during pregnancy, testing at an early prenatal visit would allow for identification of women who could benefit from treatment. Testing early in pregnancy also could inform pregnancy and delivery management per the Society for Maternal-Fetal Medicine recommendations for a preference for amniocentesis over chorionic villus sampling and for avoiding internal fetal monitoring, prolonged rupture of the membranes, and episiotomy (44). Testing at an early prenatal visit harmonizes testing for hepatitis C with testing for other infectious diseases during pregnancy; however, this strategy might miss women who acquire HCV infection later during pregnancy. Pregnant women with ongoing risk factors tested early in pregnancy could undergo repeat testing later in pregnancy to identify those who acquired HCV infection later in pregnancy. Hepatitis C screening during pregnancy should be an opportunity to promote a dialogue between the pregnant woman and her medical provider about hepatitis C transmission and risk factors.
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15.104 + deorum + Ω. As the editor notes, deorum was interpolated from 1.32. All of the conjectures in the apparatus provide a genitive plural dependent on uictibus, even though the genitive may be nothing more than a false lead due to the interpolated deorum. An epithet for uictibus is also a possibility; cruentis has the advantage of giving us a picture of the bloody meal and of conveying the moral pollution attendant upon it.
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