London School of Hygiene & Tropical Medicine

Current treatments are able to cure hepatitis C at a relatively low cost to the NHS. This provides a great opportunity to find and treat those currently infected, curing the infection before the onset of liver failure or liver cancer. Testing is currently offered to those who are identified as being at high risk of infection. However, the way in which testing is provided needs to change in order to increase the number of people diagnosed and receiving treatment. Testing needs to be expanded to reach more people that it currently does.

The prevalence of hepatitis C is high in the USA, with the highest prevalence amongst the ‘baby boomer’ population – those born from 1945 to 1965. This led to a birth cohort screening recommendation, in which anyone born in this birth cohort would receive a hepatitis test if they had not had one before.

No studies have looked at how effective a birth cohort screening intervention would be in England. Those born from the 1950s to the mid-1980s and receiving a hepatitis C test have a high probability of testing positive (3.7% - 6.5%). However, this is most likely due to a higher proportion of these individuals presenting with symptoms of liver disease as their disease progresses, which is less likely for those at a younger age.

To consider how testing could be provided to particular birth cohorts, we analysed whether a birth cohort screening intervention could represent a cost-effective way of identifying those living with undiagnosed hepatitis C. We considered the possibility of adding testing onto the NHS health check, a health check performed for those aged between 40 and 74 years old every five years, as a way to provide opportunity testing.

Using economic modelling, we estimated how effective testing might be, in the absence of any empirical study assessing effectiveness.

We found that birth cohort screening could be cost-effective when performed as part of the NHS health check. In particular, we found that testing would be cost-effective in younger birth cohorts, with testing those born in the 1970s most likely to be cost-effective.

Whilst our analysis provides some important findings, more research needs to be done in order to evaluate whether hepatitis C testing on the NHS health would be acceptable to health check providers and attendees, to avoid any reduction in the health check attendance and avoid any disruption to how the health check is provided. Our results provide justification for this additional research, which should evaluate the feasibility of birth cohort screening and reduce the uncertainty in our results.

We also evaluated where future research would provide the most value, by reducing uncertainty. Our analysis suggests research should focus on the care pathway (ensuring as many of those testing positive receive treatment), the utility benefit associated with sustained virologic response, and the rate of at which disease progression occurs.

The National Institute for Health and Clinical Excellence (NICE) highlighted the possibility of adding hepatitis C screening to an existing health service in their hepatitis testing guidelines, but stopped short of making a recommendation due to lack of information on cost-effectiveness. Our study helps to fill that gap and brings hepatitis C screening potentially a step closer.

Publication

Jack Williams, Alec Miners, Ross Harris, Sema Mandal, Ruth Simmons, Georgina Ireland, Matthew Hickman, Charles Gore, Peter Vickerman. The Cost-Effectiveness of One-Time Birth Cohort Screening for Hepatitis C as Part of the National Health Service Health Check Programme in England. Value in Health. DOI: 10.1016/j.jval.2019.06.006