Diabetes Standards of Care and Resources for Clinicians and Educators
Hepatitis C and Tuberculosis Screening
Screening people with diabetes to identify chronic infections, such as hepatitis C virus (HCV) and tuberculosis, is important because these infections can be asymptomatic and difficult to diagnose. Early detection of chronic HCV infection and tuberculosis lets clinicians provide treatments that can prevent serious complications.
Clinical Practice Recommendations
Recommendations for Hepatitis C and Tuberculosis Screening
Hepatitis C (HCV)
HCV infection is a leading cause of chronic hepatitis, cirrhosis, and liver cancer. American Indians and Alaska Natives have the highest rate of acute HCV infection in the United States. The World Health Organization estimates that 55% to 85% of patients with acute HCV eventually develop chronic HCV.
Who to Screen
- Adults 18 years and older, including people with diabetes, at least once for HCV infection, regardless of their risk factors.
- All pregnant persons, regardless of age, during each pregnancy.
- People at higher risk of HCV exposure (see CDC Recommendations for Hepatitis C Screening Among Adults – United States, 2020). Exit Disclaimer: You Are Leaving www.ihs.gov
How to Screen
Use an anti-HCV antibody testing option:
- Point-of-care test (also known as rapid diagnostic test) on a fingerstick capillary or venipuncture whole-blood sample
- Laboratory-based HCV ELISA test on a serum sample
How to Diagnose Chronic HCV Infection
- For individuals with a positive HCV antibody screening test result, perform the laboratory-based HCV RNA PCR test to confirm the presence of HCV.
- The presence of HCV indicates active infection. These individuals should be referred for direct acting anti-viral (DAA) agents treatment.
- The absence of HCV indicates no active infection.
- For individuals with a negative HCV antibody test result who might have been exposed to HCV within the previous 6 months, perform an HCV RNA PCR or follow-up HCV antibody test at least 6 months after exposure.
Treatment and Monitoring
- DAA treatments cure more than 90% of chronic HCV infections.
- The Indian Health Service National Core Formulary Exit Disclaimer: You Are Leaving www.ihs.gov has several U.S. Food and Drug Administration-approved DAA therapies.
- Chronic HCV infection treatment guidance can be found at HCV Guidelines.org Exit Disclaimer: You Are Leaving www.ihs.gov from the American Association for the Study of Liver Diseases and Infectious Diseases Society of America.
- Monitor blood sugar levels during and after DAA treatment.
- Patients with diabetes taking insulin or sulfonylurea sometimes develop hypoglycemia, which may require adjustments to the doses of these medications. In some circumstances, patients with diabetes taking DAA agents develop hyperglycemia.
- Patients without diabetes taking DAA agents can develop new-onset diabetes.
An estimated 30% of individuals with diabetes and untreated latent TB infection (LTBI) develop active TB at some point in their lives. LTBI treatment can usually prevent this TB reactivation.
Perform a tuberculosis screening test at least once after a diabetes diagnosis.
Two screening tests are available:
- Tuberculin Skin Test
- The purified protein derivative (PPD) skin test is used in the United States.
- Patients must return for a second visit 48 to 72 hours after tuberculin skin test placement so that a provider can look for a reaction. At least 10 mm of induration (swelling and hardening of the skin) is considered a positive result in people with diabetes.
- Interferon-Gamma Release Assay (IGRA) Test
- The two IGRA tests approved by the U.S. Food and Drug Administration are the QuantiFERON®-TB Gold In-Tube test and T-SPOT®.TB test.
- The IGRA test uses a single blood sample and requires only one visit. The test result consists of a positive or negative finding.
Evaluate patients with positive test results for active disease. See Official American Thoracic Society/Infections Diseases Society of America/Centers for Disease Control and Prevention Clinical Practice Guidelines: Diagnosis of Tuberculosis in Adults and Children for more on diagnosing TB. Exit Disclaimer: You Are Leaving www.ihs.gov
There are a number of recommended options for LTBI treatment. Rifamycin-based regimens which include rifampin or rifapentine with isoniazid are effective and safe.
For guidance on treatment regimens and drug doses, see Guidelines for the Treatment of Latent Tuberculosis Infection: Recommendations from the National Tuberculosis Controllers Association and CDC, 2020. Exit Disclaimer: You Are Leaving www.ihs.gov [PDF]
Clinician and Educator Resources
Featured Hepatitis C Screening Resources
Featured Tuberculosis Screening Resources
Official American Thoracic Society/Infections Diseases Society of America/Centers for Disease Control and Prevention Clinical Practice Guidelines: Diagnosis of Tuberculosis in Adults and Children. Exit Disclaimer: You Are Leaving www.ihs.gov
American Thoracic Society, Infectious Disease Society of America, and CDC
Patient Education Resources
Hepatitis C Screening Patient Education Resources
Tuberculosis Screening Patient Education Resources
Tuberculosis Screening CME Trainings
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New Dangerous Liaisons: The Intersection of Diabetes and Hepatitis C Exit Disclaimer: You Are Leaving www.ihs.govJorge Mera, MD, FACP
Director, Infectious Diseases
Cherokee Nation Health Services
(Originally presented on 01/28/22.)