Comparison of hepatitis C virus testing strategies: birth cohort versus elevated alanine aminotransferase levels

Am J Prev Med. 2014 Sep;47(3):233-41. doi: 10.1016/j.amepre.2014.05.011.


Background: Hepatitis C virus (HCV) infection is unidentified in an estimated 40%-85% of infected adults. Surveillance and modeling data have found significant increases in HCV-associated morbidity and mortality.

Purpose: To compare two HCV antibody (anti-HCV) testing strategies based on (1) elevated alanine aminotransferase levels (ALT) and (2) a birth cohort approach for people born during 1945-1965.

Methods: Data from 19,055 adults aged 20-70 years who completed the National Health and Nutrition Examination Survey in 1999-2008 were analyzed in 2013. Two independent models were evaluated, based on membership in the 1945-1965 birth cohort or elevated ALT, to compare the number of identified anti-HCV-positive (anti-HCV+) individuals; proportion of total identified cases; and the number of people that would be tested using either strategy.

Results: The prevalence of anti-HCV among adults aged 20-70 years was estimated at 2.0% (95% CI=1.8%, 2.3%), representing about 3.6 million people. The birth cohort strategy would result in testing about 85.4 million people and identifying nearly 2.8 million anti-HCV+ people with a sensitivity of 76.6%. The ALT strategy would test about 21.5 million adults and identify approximately 1.8 million anti-HCV+ people with a sensitivity of 50.0%. Implementing both strategies concurrently would identify 87.3% of anti-HCV+ adults.

Conclusions: The birth cohort strategy, which is recommended by both the CDC and the U.S. Preventive Services Task Force, would identify 1 million more anti-HCV+ people than the elevated ALT approach. Concurrent implementation would identify an even larger number of individuals ever infected.

Publication types

  • Comparative Study

MeSH terms

  • Adult
  • Aged
  • Alanine Transaminase / blood*
  • Cross-Sectional Studies
  • Female
  • Hepatitis C / diagnosis*
  • Hepatitis C / epidemiology
  • Hepatitis C Antibodies / blood*
  • Humans
  • Male
  • Middle Aged
  • Nutrition Surveys
  • Prevalence
  • Sensitivity and Specificity
  • United States / epidemiology
  • Young Adult


  • Hepatitis C Antibodies
  • Alanine Transaminase