Screening for HCV
=================

* Fiona G. Kouyoumdjian
* Aaron Orkin
* Kathleen Dooling
* Michael Schwandt

We applaud Shah and colleagues1 for raising the issue of establishing a Canadian screening program for hepatitis C. We agree that hepatitis C shows the hallmarks of an infectious disease suited to a screening program,2 but we are concerned that the extrapolation of American data into the Canadian context may hamper our ability to make a sound homegrown decision.

We do not think that Philadelphia clinic data from 2004–2005 or a 1999 national US survey provide valid evidence that “[p]rimary care providers may be unaware of the risk factors for HCV infection” in Canada or that they “do not have time or knowledge to provide counselling.”1 Primary care involvement and expertise are appropriately central to screening programs in Canada, and we advocate for Canadian research on screening for hepatitis C in the context of primary care.

Cost-effectiveness estimates from the United States on screening those born between 1945 and 1965 are compelling but may not be relevant in Canada, given differences in access to health care services, and differences in the estimated hepatitis C prevalence in this birth cohort: 3.25% in the US3 and 1.2% in Canada.4

We suggest a systematic assessment of various screening strategies. Screening the 14 million people in this birth cohort,5 even once, would bear substantial opportunity costs. Targeted alternatives, such as screening on admission to correctional facilities, merit more consideration. There are 250 000 admissions each year to correctional facilities in Canada;6 the hepatitis C prevalence in this setting is 18.7% overall and 61.3% among inmates who have injected drugs (about 30% of inmates).4 A targeted strategy in the correctional system could identify tens of thousands of people with hepatitis C.

## References

1.  Shah HA, Heathcote J, Feld JJ. A Canadian screening program for hepatitis C: Is now the time? CMAJ 2013;185:1325–8.
    
    [FREE Full Text](http://www.cmaj.ca/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiRlVMTCI7czoxMToiam91cm5hbENvZGUiO3M6NDoiY21haiI7czo1OiJyZXNpZCI7czoxMToiMTg1LzE1LzEzMjUiO3M6NDoiYXRvbSI7czoyMjoiL2NtYWovMTg2LzQvMjk0LjIuYXRvbSI7fXM6ODoiZnJhZ21lbnQiO3M6MDoiIjt9) 

2.  Wilson JMG, Jungner G. Principles and practice of screening for disease. Geneva: World Health Organization; 1968.
    
    

3.  Smith BD, Morgan RL, Beckett GA, et al. Hepatitis C virus testing of persons born during 1945–1965: recommendations from the Centers for Disease Control and Prevention. Ann Intern Med 2012;157: 817–22.
    
    [CrossRef](http://www.cmaj.ca/lookup/external-ref?access_num=10.7326/0003-4819-157-9-201211060-00529&link_type=DOI) 
    
    [PubMed](http://www.cmaj.ca/lookup/external-ref?access_num=22910836&link_type=MED&atom=%2Fcmaj%2F186%2F4%2F294.2.atom) 

4.  Remis R. Modelling the incidence and prevalence of hepatitis C infection and its sequelae in Canada, 2007. Ottawa (ON): Public Health Agency of Canada; 2007.
    
    

5.  Adult correctional statistics in Canada, 2010/2011. Ottawa (ON): Statistics Canada; 2012. Cat. no. 85-002-X.
    
    

6.  Adult correctional services, admissions to provincial, territorial and federal programs (Canada). Ottawa (ON): Statistics Canada; 2012; Available: [www.statcan.gc.ca/tables-tableaux/sum-som/l01/cst01/legal30a-eng.htm](http://www.statcan.gc.ca/tables-tableaux/sum-som/l01/cst01/legal30a-eng.htm) (accessed 2013 Nov. 10).