Evaluation and comparison of risk-based and universal prenatal HCV screening programs in Alberta, Canada

L Alexa Thompson; Sabrina S Plitt; Karen Doucette; Carla S Coffin; Kristin B Klein; Joan L Robinson; Carmen L Charlton

doi:10.1016/j.jhep.2023.05.044

Evaluation and comparison of risk-based and universal prenatal HCV screening programs in Alberta, Canada

J Hepatol. 2023 Nov;79(5):1121-1128. doi: 10.1016/j.jhep.2023.05.044. Epub 2023 Jun 20.

Authors

L Alexa Thompson¹, Sabrina S Plitt², Karen Doucette³, Carla S Coffin⁴, Kristin B Klein⁵, Joan L Robinson⁶, Carmen L Charlton⁷

Affiliations

¹ Division of Diagnostic and Applied Microbiology, Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Alberta, Canada; Women and Children's Health Research Institute (WCHRI), University of Alberta, Edmonton, Alberta, Canada.
² Public Health Agency of Canada, Ottawa, Ontario, Canada; School of Public Health, University of Alberta, Edmonton, Alberta, Canada.
³ Division of Infectious Diseases, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada; Li Ka Shing Institute of Virology, Edmonton, Alberta, Canada.
⁴ Division of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.
⁵ Provincial Population and Public Health, Alberta Health Services, Alberta, Canada; Department of Medicine, University of Alberta, Edmonton, Alberta, Canada.
⁶ Division of Infectious Diseases, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada.
⁷ Division of Diagnostic and Applied Microbiology, Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Alberta, Canada; Women and Children's Health Research Institute (WCHRI), University of Alberta, Edmonton, Alberta, Canada; Li Ka Shing Institute of Virology, Edmonton, Alberta, Canada; Alberta Precision Laboratories (ProvLab), University of Alberta Hospital, Edmonton, Alberta, Canada. Electronic address: Carmen.Charlton@albertaprecisionlabs.ca.

PMID: 37348788
DOI: 10.1016/j.jhep.2023.05.044

Abstract

Background & aims: Canadian clinical practice guidelines currently recommend risk-based screening for HCV in pregnant individuals. However, no provinces or territories have ever compared the effectiveness of risk-based vs. universal screening for the prenatal diagnosis of HCV. We aimed to evaluate and compare HCV screening programs after implementing a universal population-level pilot program among prenatal patients in Alberta, Canada.

Methods: The Alberta Prenatal Screening Program for Select Communicable Diseases was amended to include universal HCV antibody screening. Cohorts of pregnant individuals screened for HCV through risk-based or universal programs were generated over 1-year periods. HCV screening rates and prevalence were analyzed and compared between cohorts to evaluate the effectiveness of screening methods. Social and demographic risk factors for HCV-positive individuals were compared between screening cohorts to identify which populations may be overlooked with risk-based guidelines.

Results: HCV antibody screening rates were 11.9% and 99.9% among pregnant individuals in the risk-based and universal cohorts, respectively. HCV prevalence among the cohorts was 0.07% and 0.11% (difference = 0.04%, p = 0.032), with an average of 21 additional HCV-positive pregnant individuals identified annually with universal screening. HCV-positive pregnant patients diagnosed through universal screening were more likely to engage in high-risk sexual behaviours/sex work compared to those diagnosed through risk-based screening (47.6% vs. 12.5%, respectively p = 0.035), suggesting that these high-risk cases are being missed by risk-based screening.

Conclusions: Universal HCV screening diagnoses significantly higher numbers of pregnant individuals infected with HCV compared to risk-based screening. Universal HCV screening or amending risk-based guidelines to incorporate more proxy variables for risk factors should be considered to improve prenatal HCV screening guidelines in Canada and help achieve HCV elimination in the next decade.

Impact and implications: HCV is a bloodborne pathogen that can cause severe liver disease and be vertically transmitted from a mother to her baby during pregnancy. Pregnant individuals in Alberta are currently only tested for HCV if they disclose engaging in activities that put them at risk of acquiring the infection (risk-based screening). Using a population-wide universal prenatal HCV screening program, our work shows that testing based on patient disclosed risk alone leads to the significant underdiagnosis of HCV in pregnant individuals and suggests individuals engaging in sex work or risky sexual behaviours are being overlooked by the current risk-based program. Our outcomes represent the first province-wide study to evaluate and compare prenatal HCV risk-based and universal screening programs in Canada and provide evidence to support the update of prenatal HCV screening policies across the country and in similar jurisdictions.

Keywords: Alberta; HCV; communicable disease; diagnosis; prenatal; risk-based; screening; universal.