Hepatitis C: Why Screening Is Important for Baby Boomers and Millennials

[Updated on October 5, 2020]

Unlike most viruses, hepatitis C (HCV) has no symptoms. In fact, many people with HCV have no idea that they have this serious, blood-borne viral infection. 

The word “hepatitis” means inflammation of the liver. A particular kind—hepatitis C—can be passed through contact with an infected person’s blood from injection drug use, intranasal drug use, an unsterile tattoo needle, blood transfusions (before 1992), or, less commonly, through sexual intercourse with an infected person, particularly among HIV-infected individuals and men who have sex with men. And there’s no vaccine to prevent contracting it. 

“Hep C is known as a silent killer,” says Joseph Lim, MD, a Yale Medicine hepatologist (liver specialist) and director of the Yale Medicine Viral Hepatitis Program. “People who have it are asymptomatic—they don’t usually feel sick. That’s because the virus causes a low level of inflammation.” But over time, the hep C virus can lead to fibrosis (liver scarring), cirrhosis (when a large amount of liver tissue is replaced by scar tissue), and occasionally liver cancer. “By the time people have symptoms of hepatitis C, such as jaundice (yellowing of skin and eyes), they may already have liver failure,” says Dr. Lim. Hepatitis C is now recognized as the most lethal infectious disease, accounting for more deaths than HIV and 59 other infectious diseases combined, according to a 2018 article in The New England Journal of Medicine.

Nearly 2.4 million people in the United States had chronic hepatitis C infections between 2013 and 2016, according to a 2018 release by the Centers for Disease Control and Prevention (CDC). Because many have no symptoms, more than 50% of infected people remain undiagnosed, says Dr. Lim. Although your body can, in some cases, fight off this virus infection on its own when first exposed, it’s estimated that 75 to 85% of infected people fail to clear the infection, which will transition to a chronic infection.  

In April of 2020, the CDC announced additions to existing HCV screening recommendations: All people aged 18 or older should be screened for the disease at least once in their lifetime, and all pregnant women should also be screened during each pregnancy. While both recommendations come with the qualification that the screening is not necessary in areas where the HCV prevalence is less than 0.1%, the CDC press release emphasized that regardless of age or prevalence, all people with risk factors should still receive periodic screening.

“Any person who requests hepatitis C testing should receive it, regardless of disclosure of risk, because many persons might be reluctant to disclose stigmatizing risks,” the release states.

Up until recently, only baby boomers—born 1945 to 1965—were advised to get tested. According to the National Institutes of Health, over 75% of U.S. adults with HCV are baby boomers, many of whom contracted HCV several decades ago and may not view themselves as high risk individuals for this infection, explains Dr. Lim.

But they are not the only group who should be screened, because the number of people with hepatitis C—including younger adults—tripled in the five years between 2010 and 2015, according to the CDC. That’s what, in part, has prompted changes to the guidelines. 

“An increase in hep C infections among 18- to 35-year-olds is closely associated with the opioid epidemic,” says Dr. Lim. “A majority are young people recently infected in the context of drug use.” Many started with opioid prescription pain medications and moved on to use less expensive injectable drugs such as heroin or start snorting cocaine through shared straws contaminated with HCV-infected blood.  

Hep C infections among younger adults is a problem affecting primarily non-urban areas of the country, particularly in the New England, Appalachian, and Midwestern regions, according to the CDC. 

“Currently, hep C represents the number one cause of liver failure and transplant in the United States,” says Dr. Lim. With an increased number of adults soon to be screened, Dr. Lim is hoping to see the number of new cases of liver disease from HCV go down.  

Earlier diagnosis is particularly important now that there is an effective treatment. Until 2014, treatment required an  injection-based treatment called interferon, which was not all that effective and also caused significant toxicity (similar to chemotherapy). Now, new oral combinations of direct-acting antivirals (DAAs) have emerged; they are highly effective and have significantly reduced side effects. Treatment for most patients consists of a short course of 1 to 3 pills per day for 2 to 3 months. “We now have the capacity to cure hep C in 95 percent of cases,” Dr. Lim says.

Even those who receive effective treatment should still be monitored for liver cancer throughout their lives, say Mario Strazzabosco, MD, director of the Liver Cancer Program at Smilow Cancer Hospital. “With the new medication against hepatitis C, even if we eradicate the virus, we do not fully eliminate the risk [of liver cancer]. There is still a sizable remaining risk. In fact, most often the patient has a combination of risk factors. Once the HCV is cleared, we still need to address the additional risk related to diabetes, obesity, alcohol, smoking, and others. When we see a patient at the Smilow Liver Cancer Program, we address all of these risk factors.” 

Yet, the recent shifts in screening to include a broader range of people should enable diagnosis and treatment to begin long before the virus has the chance to severely damage the liver.

“We have the opportunity to eradicate hep C,” Dr. Lim says. “For us to achieve that goal, we need to identify the large number of Americans who are still undiagnosed.”

Read a summary of our liver series.  

Read part 1 of our liver series—on the rise of liver disease in young people.  

Read part 2 of our liver series—on one patient's unexpected diagnosis of nonalcoholic steatohepatitis (NASH).

Additional reporting by Valerie Pavilonis.