Letters to the Editor

[6] Tergast TL, Blach S, Tacke F, et al. Updated epidemiology of hepatitis C virus hepatitis risk scenarios. J Hepatol 2015;62:1256–1264. https://doi.org/10.
infections and implications for hepatitis C virus elimination in Germany. J Viral 1016/j.jhep.2015.01.011.
Hepat 2022;29:536–542. https://doi.org/10.1111/jvh.13680. [8] Biallas R, Steffen G, Burdi S, et al. Anstieg der übermittelten Hepatitis-B und
[7] Wolffram I, Petroff D, Bätz O, et al. Prevalence of elevated ALT values, HBsAg, Hepatitis-C-Fälle in Deutschland im Jahr 2022 Epid. Bull 2023;31:3–16.
and anti-HCV in the primary care setting and evaluation of guideline defined https://doi.org/10.25646/11669.

Reply to: “Population-based screening works: Effect of

integrating screening for hepatitis B and C into the general
health check-up in Germany”

Evaluation and comparison of risk-based and universal US over 18 at least once in their lifetime, except where prev-
HCV screening programs alence is below 0.1%.7 However, Canada has yet to follow suit,
and as policies in other parts of North America and Europe
To the Editor: forge ahead to recommend one-time universal HCV screening
We would like to thank Hüppe et al. for their interest in our for all adults, screening of individuals in Canada continues to
article.1 We greatly appreciate their interest in our population- rely on risk-based disclosure. Our data in Fig. 1 further
based study and the opportunity to further discuss the impor- demonstrates that little progress has been made in increasing
tance of removing risk-based screening from guidelines if HCV risk-based screening rates among those in the birth cohort
is to be eliminated as a global public health threat. without population-based programs in place.
Our universal prenatal HCV screening study was initiated as There is an urgent need for population-based screening to
a result of the opioid crisis in North America, which increased be implemented across national elimination strategies. Data
rates of HCV among women of childbearing-age in Canada.2 from our study and Hüppe et al. are only two of many examples
Research from other jurisdictions had previously suggested that support the benefits of population-based screening. While
prenatal HCV risk-based screening is ineffective, as it relies cost-effectiveness should be considered, and is often cited as
on patients to disclose potentially stigmatizing risk factors a concern for implementing large-scale testing programs,
about themselves to healthcare providers,3 which was systematic reviews have shown birth cohort, universal, and
corroborated in our Canadian study, where we found Alberta age-based general population testing to be cost-effective
pregnant women engaging in high-risk sexual behaviours or across 30 different studies.8 As we continue to generate
sex work were less likely to receive an HCV diagnosis through evidence-based data that support the implementation of
risk-based screening programs. population-based screening, the onus is on policy makers and
Although our universal screening study was limited to the national representatives to remove risk-based screening from
prenatal population, HCV incidence has recently been
increasing in other populations across Canada,4 highlighting
the need for more effective population-based screening stra-
tegies overall. Data shared from Hüppe et al. demonstrate the Population in 2021 (n) Screened for HCV in 2021 (n)

benefits of population-based HCV screening among individuals 2.5x106 4.24%

over the age of 35 in Germany,5 with 18-40% of individuals

receiving HCV screening through the “Check-Up 35” program 2.0x106
between quarters in 2021 and 2022. In comparison, the 2021
population-standardized rate of HCV risk-based screening in 1.5x106
Alberta, Canada was only 4.24% for individuals over the age of
35 (Fig.1), a 4.5 to 10-fold lower screening rate than observed in 1.0x106
Germany. These data support the need to transition from risk- 5.74% 3.05%
3.51%
4.66%
based screening to population-based programs for the benefit 0.5x106
of all groups of people, regardless of age or risk factor status.
In 2016, a provincial health technology assessment was 0
published in Alberta, Canada which showed universal 35-44 45-54 55-64 65+ Total
screening by birth cohort (those born between 1945 and 1975) HCV risk-based screening rates by age population (35+)
would be more effective at diagnosing HCV among a high
Fig. 1. HCV risk-based screening rates among individuals aged 35 and
prevalence population and would be cost effective.6 That same above in Alberta, Canada in 2021, stratified by age group. n: sample size
year, the US CDC (Centre for Disease Control and Prevention) represented in counts. Prenatal women were excluded from dataset due to uni-
recommended one-time universal HCV screening for those in versal prenatal HCV screening availability in Alberta. Population estimates
the birth cohort, and in 2020 the United States CDC recom- excluded individuals with a history of HCV antibody positivity as they would be
excluded from receiving HCV antibody screening.
mended one-time universal HCV screening for all adults in the

e176 Journal of Hepatology, April 2024. vol. 80 j e143–e177

 Letters to the Editor

4
guidelines and transition to population-based programs for the Alberta Precision Laboratories (ProvLab), University of Alberta Hospital,
benefit of patients everywhere. Edmonton, Alberta, Canada
5
We again want to thank Hüppe et al. for their ongoing work Canadian Blood Services, Edmonton, Alberta, Canada
*
in this area and for discussing such an important and timely Corresponding author. Address: 2B2.12 WMC, 8440-112 Street,
matter as the world moves towards achieving HCV elimination. Edmonton, Alberta, T6G 2J2, Canada, Tel.: 1-780-407-8975.
E-mail address: Carmen.Charlton@albertaprecisionlabs.
ca (C.L. Charlton)
L. Alexa Thompson1,2
Carmen L. Charlton1,2,3,4,5,* Received 12 December 2023; Accepted 13 December 2023; Available
1
Division of Diagnostic and Applied Microbiology, Department of online 4 January 2024
Laboratory Medicine and Pathology, University of Alberta, Edmonton, https://doi.org/10.1016/j.jhep.2023.12.025
Alberta, Canada
2 © 2024 European Association for the Study of the Liver. Published by
Women and Children’s Health Research Institute (WCHRI), University
Elsevier B.V. All rights reserved.
of Alberta, Edmonton, Alberta, Canada
3
Li Ka Shing Institute of Virology, Edmonton, Alberta, Canada

Financial support [2] Mendlowitz AB, Feld JJ, Biondi MJ. Hepatitis B and C in pregnancy and
children: a Canadian perspective. Viruses 2023;15. https://doi.org/10.
The authors did not receive any financial support to produce this manuscript.
3390/V15010091.
[3] Boland JH, Crockett A, Ewing A. Risk-based screening vs universal screening
Conflicts of interest for hepatitis C in pregnancy: a retrospective cohort study Poster Session I.
Am J Obstet Gynecol 2020;224:S143. https://doi.org/10.1016/j.ajog.2020.
The authors have no conflicts of interest to disclose.
12.237.
Please refer to the accompanying ICMJE disclosure forms for further details.
[4] Government of Canada. Hepatitis C in Canada: 2019 surveillance data n.d.
https://www.canada.ca/en/public-health/services/publications/diseases-
Authors’ contributions conditions/hepatitis-c-2019-surveillance-data.html (accessed August
18, 2022).
Conceptualization, AT; CLC; Methodology, AT; Data curation, AT; Formal anal-
[5] Hüppe D, Wedemeyer H, Cornberg M. Population-based screening works:
ysis, AT; Software, AT; Validation, AT; CLC; Writing-original draft, AT; Writing-
effect of integrating screening for hepatitis B and C into the general health
review&editing, AT; CLC; Supervision, CLC.
check-up in Germany. J Hepatol 2023;0. https://doi.org/10.1016/j.jhep.2023.
10.034.
Supplementary data [6] The Health Technology Assessment Unit U of C. Hepatitis C screening in
Alberta. 2016.
Supplementary data to this article can be found online at https://doi.org/10.1016/
[7] Havens PL, Anderson JR. Updated CDC recommendations for universal
j.jhep.2023.12.025.
hepatitis C virus screening among adults and pregnant women: implications
for clinical practice. JAMA 2020;323:2258–2259. https://doi.org/10.1001/
References JAMA.2020.3693.
[1] Thompson LA, Plitt SS, Doucette K, et al. Evaluation and comparison of risk- [8] Carty PG, Fawsitt CG, Gillespie P, et al. Population-based testing for undi-
based and universal prenatal HCV screening programs in Alberta, Canada. J agnosed hepatitis C: a systematic review of economic evaluations. Appl
Hepatol 2023;S0168–8278(23):1121–1128. https://doi.org/10.1016/j.jhep. Health Econ Health Pol 2022;20:171–183. https://doi.org/10.1007/S40258-
2023.05.044. 021-00694-W.

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