Common Blood-borne Pathogen Research Articles

Transmission of haemotropic mycoplasma in the absence of arthropod vectors within a closed population of dogs on ectoparasiticides

Dog-infecting haemotropic mycoplasmas (haemoplasmas), such as Mycoplasmahaemocanis and Candidatus Mycoplasma haematoparvum are common blood-borne pathogens of canines that can potentially inflict a substantial burden of disease, particularly in immunosuppressed individuals. Nonetheless, the transmission of these pathogens remains debated as more evidence emerges that they may not be transmitted by vectors, but instead use alternative methods such as aggressive interactions and vertical transmission. Here, we treated forty dogs with two different topically-acting ectoparasiticide products able to prevent vector-borne pathogen infections during an 8-month community trial in Cambodia. A total absence of ectoparasites were observed at all time points, and no new infections caused by pathogens confirmed as being vectorially-transmitted were detected, i.e., Babesiavogeli, Ehrlichiacanis, Anaplasmaplatys, and Hepatozooncanis. Conversely, the number of haemoplasma infections in dogs on both ectoparasiticides rose significantly, with an incidence of 26 infections per 100 dogs at risk per year, providing strong evidence of non-vectorial transmission. Over the study period, dog aggression and fighting were frequently observed, highlighting a different potential mode of transmission. This study presents the first robust evidence that canine haemoplasmas may be transmitted without arthropod vectors drawing attention to the need for new methods to prevent their transmission.

Machine-learning-based predictions of direct-acting antiviral therapy duration for patients with hepatitis C

IntroductionHepatitis C, which affects 71 million persons worldwide, is the most common blood-borne pathogen in the United States. Chronic infections can be treated effectively thanks to the availability of modern direct-acting antiviral (DAA) therapies. Real-world data on the duration of DAA therapy, which can be used to optimize and guide the course of therapy, may also be useful in determining quality of life enhancements based upon total required supply of medication and long-term improvements to quality of life. We developed a machine learning model to identify patient characteristics associated with prolonged DAA treatment duration. MethodsA nationwide U.S. commercial managed care plan with claims data that covers about 60 million beneficiaries from 2009 to 2019 were used in the retrospective study. We examined differences in age, gender, and multiple comorbidities among patients treated with different durations of DAA treatment. We also examined the performance of machine learning models for predicting a prolonged course of DAA based on the area under the receiver operating characteristic curve (AUC). ResultsWe identified 3943 cases with hepatitis C who received sofosbuvir/ledipasvir as the first course of DAA and were eligible for the study. Patients receiving prolonged treatment (n = 240, 6.1%) were more likely to have compensated cirrhosis, decompensated cirrhosis, and other comorbidities (P < 0.001). For distinguishing patients who received prolonged DAA treatment for hepatitis C from patients received standard treatment, the optimal predictive model, constructed with XGBoost, had an AUC of 0.745 ± 0.031 (P < 0.001). ConclusionsThe risk of antiviral resistance and the cost of DAA are strong motivators to ensure that first-round DAA therapy is effective. For the dominant DAA treatment during the course of this analysis, we present a model that identifies factors already captured in established guidelines and adds to those age, comorbidity burden, and type 2 diabetes status; patient characteristics that are predictive of extended treatment.

Hepatitis C Virus.

Hepatitis C virus (HCV) is the most common bloodborne pathogen in the United States, chronically affecting approximately 2.4 million Americans, most of whom are unaware of the infection. Highly effective, well-tolerated therapies are now available with markedly simplified treatment algorithms. Eradication of HCV is a national goal. Increased efforts to extend access to treatment to populations that traditionally are difficult to treat, such as persons who inject drugs, are critical to achieving eradication. Given the magnitude of the disease burden, an increased role of primary care providers in screening, patient stratification, and treatment will be needed.

Annals for Educators - 1 September 2020.

Annals for Educators - 1 September 2020.

Reproductive system infections in women: upper genital tract, fetal, neonatal and infant syndromes.

Lower genital tract infection and bloodborne spread of infection are the two principal modes for infection of the upper genital tract or for infection of the fetus, neonate or infant. Treponema pallidum and human immunodeficiency virus (HIV) are the two most common bloodborne pathogens that infect the fetus, neonate or infant. Most infections of the upper genital tract, however, spread along epithelial surfaces from the vagina or cervix to the upper genital tract or chorioamnion, fetus, neonate or infant. These infections are caused by either pathogens associated with a dysbiotic vaginal microbiome or those that are sexually transmitted. The clinical syndromes that these pathogens produce in the lower genital tract were discussed in part one of this review. We now discuss the syndromes and pathogens that affect the upper genital tract of both non-pregnant and pregnant women as well as fetus, neonate and infant.

1035 Hepatitis C Virus Screening Practices by Medical Residents in a Federally-Qualified Health Center

INTRODUCTION: Hepatitis C virus (HCV) is the most common chronic blood-borne pathogen in the United States. Treatment for HCV infection is currently available, curative, and with few associated side effects, increasing the importance of identifying HCV-infected individuals. HCV screening guidelines recommend a 1-time screening for baby boomers (individuals born between 1945 and 1965). Baby boomers have a higher risk for HCV-related morbidity and mortality. As of 2015, less than 13% of this population has undergone screening for HCV infection. This study aims at quantifying the baseline screening rates amongst baby boomers in a medical residents’ community clinic and evaluating the impact of resident-targeted interventions on HCV screening rates. METHODS: A retrospective chart review of baby boomers seen by medical residents between 7/1/17 and 12/31/18 was performed. Patients had to be seen at least once for a physical exam by the medical resident during the study period, and not screened for HCV infection previously. Baseline screening rates were recorded. Interventions were implemented for a period of 4 months. These included an updated electronic medical record (EMR) reminder for screening based on birth year, an EMR HCV risk assessment tool to identify patients need testing before visit, a link to HCV screening indications and guidelines, and small group teaching sessions about testing and linking patients to appropriate posttest care. A second phase of data collection included a chart review of baby boomers seen between 2/1/19 and 5/31/19 and meeting same criteria. A paired comparison t-test is used to analyze results. RESULTS: This investigation includes 502 patients in the first phase and 164 patients in the second phase of data collection. Pre-intervention screening rate was 89/502 (17.7%) compared with 72/164 (43.9%) post-intervention (P value &lt; 0.0001). CONCLUSION: This investigation shows the suboptimal baseline HCV screening rate in baby boomers in a residents’ community clinic. Our post-intervention findings highlight the impact of focused resident-targeted education and the effectiveness of integrating appropriate tools into clinic infrastructure to help improve the rate of screening. Subsequently, this can help identify individuals who are in need for medical attention, potentially reducing complications of HCV infection and providing good value for our health care dollar overall.

Hepatitis C Screening in Mothers and Infants Exposed to Opioids

Hepatitis C virus (HCV) is the most common blood-borne pathogen in the United States. In the context of the opioid epidemic, there has been a dramatic rise in perinatal opioid use and the prevalence of HCV infection, which can be transmitted to infants. One national guideline recommends HCV screening for all pregnant women and screening for HCV-exposed newborns after 18 months of age. In this study, we aimed to identify the trends in HCV prevalence and screening among mothers using opioids during pregnancy and infants exposed to HCV infection in utero. Infants with International Classification of Diseases, Ninth Revision (779.5) or International Classification of Diseases, 10th Revision codes (P96.1) for neonatal abstinence syndrome and in-utero exposure to methadone, buprenorphine, or other opioid medications were identified for this retrospective cohort analysis. Information regarding maternal and infant HCV screening, demographics, and follow-up care was also extracted from the electronic medical record and HealthInfoNet, a statewide database of laboratory results. Between 2013 and 2018, 769 infants with in-utero opiate exposure were identified. The maternal HCV screening rate increased from 58.1% in 2013 to 90% in 2018. Of the mothers tested for HCV during pregnancy, 257 (47.9%) were HCV-positive. Of the 177 infants eligible for testing by age criteria, 94 (53%) were tested for HCV, and 7 (7.4%) were HCV-positive. We estimate that an additional 10 infants were HCV-positive and undiagnosed. Despite the high prevalence of HCV, rates of maternal and infant screening remain suboptimal. This study highlights the need for improved care for this high-risk population of infants born to mothers with opiate use disorder.

Comparison of Roche Elecsys and Sysmex HISCL immunoassays for the screening of common blood-borne pathogens.

We conducted a comprehensive comparison in the sensitivity, specificity, dilution sensitivity, and precision between two immunoassay systems, Roche Elecsys Cobas e 601 and Sysmex HISCL 5000, for the detection of hepatitis B virus surface antigen (HBsAg), antibody to hepatitis C virus (anti-HCV), treponemal antibodies (anti-TP), and human immunodeficiency virus (HIV). One thousand unselected samples and 100 reserved weak reactive samples were tested by the two systems. Sensitivity and specificity were then calculated for each system. Seroconversion panels were used to assess the sensitivity in early stage detection. Dilution sensitivity was evaluated by dilution tests of several seroconversion panel samples. Evaluation of within-run and intermediate precision was conducted following EP-15A protocol. The consistency rates of the two systems for the detection of four pathogens were all over 99% among unselected samples. Both Elecsys and HISCL were observed to have high sensitivity and specificity in unselected samples and weak reactive samples. Seroconversion panel tests showed that Elecsys could identify positive results earlier than HISCL in HBsAg (1 out of 4), anti-TP (1 out of 2) and HIV (1 out of 12) panels. The results of the anti-HCV panels were comparable. In dilution tests, Elecsys could detect lower concentrations than HISCL in two anti-HCV samples and one anti-TP sample. The two systems had similar performance in dilution tests of HBsAg and HIV samples. Both Elecsys and HISCL had qualified intra-assay and inter-assay precision. Both Elecsys and HISCL have good performance in the screening of four common bloodborne pathogens. The two systems are comparable and considered adequate for clinical use.

Hepatitis C in 2019: Are We There Yet?

Chronic hepatitis C is the most common blood-borne pathogen worldwide. Upwards of half of the individuals infected with hepatitis C have not been diagnosed, and rates of screening remain low. Incidence, which had been declining, began increasing in 2011, mirroring the current opioid epidemic. Once infected, people with chronic hepatitis C are at risk for developing complications including end-stage liver disease and hepatocellular carcinoma, leading to morbidity and mortality. These public health consequences of the hepatitis C epidemic are expected to increase over the coming decade. Innovation has resulted in highly tolerable medications of 8 to 16 weeks’ duration with over 90% efficacy. Experts have determined that the eradication of hepatitis C would be feasible and have laid out strategies to move us toward that goal. Significant and disparate barriers remain, including access to treatment and an increase in incidence related to the opioid epidemic. An underresourced approach to surveillance and screening, provider shortages, and payer restrictions are among the obstacles to eliminating hepatitis C as a public health problem in the United States.

Detection of Low Copy Number Integrated Viral DNA Formed by In Vitro Hepatitis B Infection.

Hepatitis B Virus (HBV) is a common blood-borne pathogen causing liver cancer and liver cirrhosis resulting from chronic infection. The virus generally replicates through an episomal DNA intermediate; however, integration of HBV DNA fragments into the host genome has been observed, even though this form is not necessary for viral replication. The exact purpose, timing, and mechanism(s) by which HBV DNA integration occurs is not yet clear, but recent data show that it occurs very early after infection. Here, the in vitro generation and detection of HBV DNA integrations are described in detail. Our protocol specifically amplifies single copies of virus-cell DNA integrations and allows both absolute quantification and single-base pair resolution of the junction sequence. This technique has been applied to various HBV-susceptible cell types (including primary human hepatocytes), to various HBV mutants, and in conjunction with various drug exposures. We foresee this technique becoming a key assay to determine the underlying molecular mechanisms of this clinically relevant phenomenon.

Detection of Low Copy Number Integrated Viral DNA Formed by &lt;em&gt;In Vitro&lt;/em&gt; Hepatitis B Infection

Hepatitis B Virus (HBV) is a common blood-borne pathogen causing liver cancer and liver cirrhosis resulting from chronic infection. The virus generally replicates through an episomal DNA intermediate; however, integration of HBV DNA fragments into the host genome has been observed, even though this form is not necessary for viral replication. The exact purpose, timing, and mechanism(s) by which HBV DNA integration occurs is not yet clear, but recent data show that it occurs very early after infection. Here, the in vitro generation and detection of HBV DNA integrations are described in detail. Our protocol specifically amplifies single copies of virus-cell DNA integrations and allows both absolute quantification and single-base pair resolution of the junction sequence. This technique has been applied to various HBV-susceptible cell types (including primary human hepatocytes), to various HBV mutants, and in conjunction with various drug exposures. We foresee this technique becoming a key assay to determine the underlying molecular mechanisms of this clinically relevant phenomenon.

Expanding care for patients infected with Hepatitis C through community partnership in Delaware.

BackgroundHepatitis C virus (HCV) is the most common blood-borne pathogen in the U.S., and Delaware has one of the highest sero-prevalence rates in the country. As a cause of significant morbidity and mortality, it is a public health priority to identify and link individuals with HCV to care. The demand of patients with HCV far exceeds the current availability of providers in Delaware that offer HCV management. ObjectiveTo propose a framework for enabling non-specialist providers within Westside Family Healthcare to manage patients with HCV.MethodsAs a recipient of a Harrington Value Institute Community Partnership grant, the HIV Community Program of Christiana Care Health System (CCHS) started working together with the NE Wilmington pilot site of Westside in July 2018 to: 1) provide HCV education to Westside, 2) implement an HCV care model at Westside, and 3) conduct programmatic evaluation of this framework’s effectiveness. Our goal is to improve Westside rates of HCV knowledge amongst patients and staff, as well as to improve the HCV care continuum, starting with universal HCV screening.Results and ConclusionsResults from the first year of collaboration will be available in August 2019. Implementation of this partnership will enable future expansion and continuation of HCV management amongst Westside sites.

Improving Hepatitis C Screening Rates in a Resident Clinic: A Quality Improvement Project

Introduction: Hepatitis C virus (HCV) is the most common chronic blood-borne pathogen in the US. HCV is a viral liver disease that can result in cirrhosis, hepatocellular carcinoma, liver transplantation or death. CDC and USPSTF recommend HCV screening for all those born between 1945 and 1965- the baby boomer population. We designed a quality improvement project seeking to improve HCV screening rates in our ambulatory resident practice. Methods: We educated all residents and clinical staffs at ambulatory clinic by lectures, emails and weekly meetings about the importance of HCV screening in the baby boomers. All residents were asked to order a HCV Antibody profile as a screening test if the patient had never been tested. In case resident forgot to order it, then staff would order at the time of check out. If the test was positive, then patients were called and informed about the result and referred to hepatitis care clinic for further work up. Results: We screened 300 patients and 10 patients had a positive HCV screening test (3.3%). Only two patients had a positive viral load (20.0%). 5 out of 10 positive HCV positive patients had an intravenous drug abuse history (50.0%). No patient had undergone previous treatment for HCV infection. All 10 patients were referred to hepatitis care center for further monitoring. Conclusion: HCV screening is recommended in the baby boomer population (born between 1945-1965), history of illicit injection drug use or intranasal cocaine use and receipt of contaminated blood products or tissue. The initial screening test for chronic HCV infection in adults is an HCV antibody test. A reactive antibody test should be followed by a HCV RNA test. A nonreactive antibody test generally indicates the absence of chronic HCV infection. HCV screening can be increased by education and appropriate follow ups. Primary care clinics can successfully increase HCV screening in a relatively short time period. Incorporating a lecture about the new HCV screening guidelines to the ambulatory educational curriculum may be a more effective and sustainable strategy to increase HCV screening rates among residents.

Hepatitis B Virus DNA Integration Occurs Early in the Viral Life Cycle in an In Vitro Infection Model via Sodium Taurocholate Cotransporting Polypeptide-Dependent Uptake of Enveloped Virus Particles.

Chronic infection by hepatitis B virus (HBV) is the major contributor to liver disease worldwide. Though HBV replicates via a nuclear episomal DNA (covalently closed circular DNA [cccDNA]), integration of HBV DNA into the host cell genome is regularly observed in the liver in infected patients. While reported as a prooncogenic alteration, the mechanism(s) and timing of HBV DNA integration are not well understood, chiefly due to the lack of in vitro infection models that have detectable integration events. In this study, we have established an in vitro system in which integration can be reliably detected following HBV infection. We measured HBV DNA integration using inverse nested PCR in primary human hepatocytes, HepaRG-NTCP, HepG2-NTCP, and Huh7-NTCP cells after HBV infection. Integration was detected in all cell types at a rate of >1 per 10,000 cells, with the most consistent detection in Huh7-NTCP cells. The integration rate remained stable between 3 and 9 days postinfection. HBV DNA integration was efficiently blocked by treatment with a 200 nM concentration of the HBV entry inhibitor Myrcludex B, but not with 10 μM tenofovir, 100 U of interferon alpha, or a 1 μM concentration of the capsid assembly inhibitor GLS4. This suggests that integration of HBV DNA occurs immediately after infection of hepatocytes and is likely independent of de novo HBV genome replication in this model. Site analysis revealed that HBV DNA integrations were distributed over the entire human genome. Further, integrated HBV DNA sequences were consistent with double-stranded linear HBV DNA being the major precursor. Thus, we have established an in vitro system to interrogate the mechanisms of HBV DNA integration.IMPORTANCE Hepatitis B virus (HBV) is a common blood-borne pathogen and, following a chronic infection, can cause liver cancer and liver cirrhosis. Integration of HBV DNA into the host genome occurs in all known members of the Hepadnaviridae family, despite this form not being necessary for viral replication. HBV DNA integration has been reported to drive liver cancer formation and persistence of virus infection. However, when and the mechanism(s) by which HBV DNA integration occurs are not clear. In this study, we have developed and characterized an in vitro system to reliably detect HBV DNA integrations that result from a true HBV infection event and that closely resemble those found in patient tissues. Using this model, we showed that integration occurs when the infection is first established. Importantly, we provide here a system to analyze molecular factors involved in HBV integration, which can be used to develop strategies to halt its formation.

Hepatitis B Virus

This infographic about hepatitis B virus explores its replication cycle, natural history of infection and pathogenesis, and how this can be controlled and treated. Hepatitis B virus (HBV) is a common worldwide blood-borne pathogen. Chronic hepatitis B can progress to an inactive carrier state, and then, in some patients, give rise to cirrhosis and cancer of the liver, leading to death. An HBV surface-antigen vaccine is effective, but treatments are currently not curative. HBV replicates via reverse transcription. Its covalently closed circular (ccc) DNA in the nucleus encodes a pregenomic RNA (pgRNA), which can be encapsidated by HBV polymerase. Reverse transcription occurs in the capsids by using the pgRNA as a template for the synthesis of single-stranded linear and then partially double-stranded relaxed circular (rc) DNA. Capsids containing a mature rc DNA genome target to the nucleus for ccc DNA synthesis. Persistent HBV infection is caused mainly by ccc DNA and immune tolerance to HBV antigens in the liver. Unlike acute infection, chronic carriers contain only a low level of HBV core-antigen-specific T cell activity, contributing to the lack of viral clearance.

Structure, Mechanics, and Instability of Fibrin Clot Infected with Staphylococcus epidermidis

Health care-associated infection, over half of which can be attributed to indwelling medical devices, is a strong risk factor for thromboembolism. Although most experimental models of medical device infection draw upon isolated bacterial biofilms, in fact there is no infection without host protein contribution. Here we study, to our knowledge, a new model for medical device infection—that of an infected fibrin clot—and show that the common blood-borne pathogen Staphylococcus epidermidis influences this in vitro model of a blood clot mechanically and structurally on both microscopic and macroscopic scales. Bacteria present during clot formation produce a visibly disorganized microstructure that increases clot stiffness and triggers mechanical instability over time. Our results provide insight into the observed correlation between medical device infection and thromboembolism; the increase in model clot heterogeneity shows that S. epidermidis can rupture a fibrin clot. The resultant embolization of the infected clot can contribute to the systemic dissemination of the pathogen.

Improving Hepatitis C Screening Rates in Primary Care

Background Hepatitis C virus (HCV) is the most common chronic blood-borne pathogen in the US. It is the leading cause of complications from chronic liver disease and the most common indication for liver transplants among US adults. National guidelines recommend one-time birth cohort based screening for adults born from 1945 to 1965 regardless of risk factors for blood-borne infections. A magnitude assessment of infectious disease outpatients demonstrated a birth cohort based screening rate of 38%. Prior quality improvement projects at other institutions have resulted in significant improvements in screening rates, with up to 90% of eligible individuals being screened. We aim to increase HCV screening by 20% amongst Primary Care Internal Medicine (PCIM) patients born from 1945 to 1965 at Mayo Clinic Rochester over a 6 month period.Methods The baseline screening rate over a 2-year period (January 1, 2015–December 31, 2016) was extracted from medical records. An anonymous online survey was created and sent to PCIM providers to assess their comfort with screening guideline recommendations and current perceived practices, as well as perform a stakeholder analysis to identify current barriers to screening. A reminder email was sent 3 weeks after the initial invitation.ResultsThe baseline screening rate was 6% (769 of 12,269 eligible visits). We attained a 30% (17/57) survey response rate after 4 weeks. Only 6% (1/17) reported screening all patients based on guideline recommendations. We found that 35% of providers are unsure who is eligible for screening. The majority (56%) cited not remembering to discuss screening, and only 18% felt very confident with their understanding of the guidelines. Other reasons for not screening per Figure 1. All providers stated they would screen more patients if there was a screening prompt, and 71% felt that providers needed more education.Conclusion Based on the results we implemented an electronic medical record tool to prompt providers to order HCV screening on patients eligible by birth cohort, who had not been previously screened, and did not have known HCV infection. Education was provided via a divisional newsletter. We are currently collecting data to analyze screening rates 6 months after implementation of our intervention.Figure 1Disclosures All authors: No reported disclosures.

Evaluating a New Approach to Inpatient Hepatitis C Virus Screening

Introduction: Hepatitis C Virus (HCV) is the most common chronic blood-borne pathogen in the U.S. and is associated with significant morbidity and mortality. In 2013, the Center for Disease Control noted that 75% of HCV-infected patients are born between 1945-1965, prompting new guidelines for screening in this population. Later, New York State implemented a law expanding screening to both outpatient and inpatients. Current literature on inpatient screening is extremely limited, with only one trial evaluating the efficacy and rates of screening. We present a retrospective study evaluating the implementation of a comprehensive HCV screening program in a large urban community hospital. Methods: In August 2015, a new HCV screening initiative was implemented. This included daily interdisciplinary rounds where patients born between 1945-1965 were identified and anti-HCV antibodies were sent. Daily rounds included an associate medical director, hospitalist, social worker, case manager, nurse manager, and Internal Medicine resident. In addition, reflexive RNA testing was introduced. Patients with positive screening tests were then referred to their primary care physician or hepatologist for follow-up. Rates of HCV screening were assessed from October 1, 2014 to December 31, 2014 and October 1, 2015 to December 31, 2015. Results: A total of 522 pre-intervention and 506 post-intervention patients were assessed. Screening rates pre-intervention was low at 4.2%. Post-intervention rates increased to 28.1%, representing a 23.9% increase in screening. 7.7% of patients screened were found to be HCV positive with no prior history of HCV. These patients had a mean age of 63.9 and the majority were either self-pay or on medicaid. Conclusion: HCV is a leading cause of chronic liver disease, cirrhosis, and hepatocellular carcinoma. Early detection and intervention are necessary to prevent end stage liver disease. Research on inpatient screening is extremely limited. We present a study demonstrating the utility of inpatient screening in identifying patients at risk. We also present a novel interdisciplinary approach to HCV screening that is effective in increasing screening rates by nearly 25%. Future research is needed to further elucidate inpatient strategies in increasing HCV screening, detection rates, and linkage to care.Figure 1

Hepatitis C Virus Postexposure Prophylaxis in the Healthcare Worker: Why Direct-Acting Antivirals Don't Change a Thing.

Currently, 380 000-400 000 occupational exposures to blood-borne pathogens occur annually in the United States. The management for occupational HIV or hepatitis B virus exposures includes postexposure prophylaxis (PEP) when necessary; however, PEP is not recommended for hepatitis C virus (HCV) exposures. Recent approval of HCV direct-acting antivirals (DAAs) has renewed discussions as to whether these therapies could be used to prevent infection after exposure. There are no published studies addressing this question, but the prescribing of DAAs for PEP has been reported. We will discuss the differences in transmission of the 3 most common blood-borne pathogens, the natural history of early HCV infection, and the scientific rationale for PEP. In particular, we will discuss how the low feasibility of conducting an adequately powered clinical trial of DAA use for PEP and the low cost-effectiveness of such an intervention is not supportive of targeting limited resources for such use.

Screening for Hepatitis C

of the Clinical Problem Hepatitis C virus affects an estimated 180 million people worldwide,making it themost common chronic blood-borne pathogen.1 Less than half of infected individuals clear their infection without treatment, and 15% to 40% of patients with HCV progress to cirrhosisorhepatocellular cancer.HepatitisCvirus infection is themost commonindication for liver transplantationand is thecauseof8000 to 13 000 deaths in the United States each year.2 SinceHCV testingofbloodproductswas implemented in 1992, the2most important risk factors forHCVacquisitionarepastor current injection drug use and birth between 1945 and 1965.3 DetectionofHCV infectionhasprovendifficultbecausebehavioral riskhistories are often incomplete, most newly infected individuals have no ormild nonspecific symptoms, and up to 50%of those infected have persistently normal serum transaminase values. Not surprisingly, 45% to85%of all personswith chronicHCV infection are unaware that they are infected.3When patients are identified and receive proper HCV treatment, they can reduce their risk of hepatocellular cancer by 70% and all-cause mortality by 50%.3