www.hivandhepatitis.com

Testing in Oakland Emergency Department Reveals High Rate of Hepatitis C Virus Infection

Hepatitis C screening at an urban emergency department revealed that 10% of patients overall had evidence of hepatitis C virus (HCV) infection -- of whom more than two-thirds had active infection -- rising to 25% among homeless people and nearly 40% among people who inject drugs, according to a study published in the August 4 online edition of Annals of Emergency Medicine. However, only about a quarter of people with confirmed positive tests were linked to follow-up medical care.

The Centers for Disease Control and Prevention and the U.S. Preventive Services Task Force recommend that all "Baby Boomers" born between 1945 and 1965 should be screened for HCV at least once as part of their routine health care, and all people at risk should be tested regularly. Yet one recent analysis found that only half of people living with HCV in the U.S. have been diagnosed.

Urban emergency departments (EDs) may play an important role as safety net providers for HCV screening because many of the 3 million Americans estimated to be infected are unaware of their status, and studies have shown high rates of ED utilization among this population, the study authors noted as background.

Douglas White from Alameda Medical System's Highland Hospital in Oakland, California, and colleagues described results from an emergency department HCV testing program that integrated birth cohort screening, testing of patients with a history of injection drug use, and diagnostic testing by physicians when clinically indicated, for example due to liver-related symptoms, according to national guidelines.

Highland Hospital's ED sees approximately 90,000 patients annually, of whom about 45% are black, 30% are Hispanic, 20% are white, and 44% are women. Approximately 85% have public insurance, 10% are uninsured, and 5% have private insurance.

Highland implemented ED-based screening for both HIV and HCV into its triage process in April 2014. This retrospective cohort study looked at data collected as part of clinical care between mid-April and the end of October. During that time a total of 26,639 adults (aged 18 or older) made 41,576 visits to the ED, indicating that some were seen more than once.

Results

• Of the 26,639 adults who presented to the ED during the 6-month study period, 2581 (9.7%) underwent HCV screening or diagnostic testing.
• Among these, 267 patients tested HCV antibody positive, for an overall prevalence of 10.3%.
• Prevalence was 9.1% among the 2028 people who received HCV screening and 14.8% among the 553 people who underwent diagnostic testing.
• Three-quarters of people who tested HCV positive were previously unaware they were infected.
• Factors associated with testing positive for HCV included:     

o   Injection drug use (38.4% prevalence; odds ratio [OR] 10.8);

o   Being homeless (25.5% prevalence; OR 3.1);

o   Receiving diagnostic testing rather than targeted screening (14.8% prevalence; OR 2.6);

o   Being in the 1945-1965 birth cohort (13.7% prevalence; OR 3.6);

o   Male sex (12.4% prevalence; OR 1.4).

• Among the 267 patients who tested positive for HCV antibodies, 180 (67.4%) underwent confirmatory HCV RNA testing, and of these 126 (70.0%) had positive results indicating active infection.
• 57 (45.2%) of the 126 patients with confirmed positive results were scheduled for follow-up appointments at the hepatitis C clinic, but only 30 people (23.8% of confirmed positives) actually attended.

"This ED screening and diagnostic testing program found a high prevalence of hepatitis C virus antibody positivity across all groups," the study authors concluded. "Our results warrant continued efforts to develop and evaluate policies for ED-based hepatitis C virus screening."

In their discussion the researchers noted that about two-thirds of patients who tested HCV antibody positive were discharged before results disclosure and confirmatory testing could be conducted. Many had their results disclosed and blood drawn for HCV RNA testing at subsequent ED visits, but the authors warned that HCV screening protocols "cannot rely on ED recidivism as a rescue tool to ensure result disclosure."

A number of patients outside of the pre-specified targeted risk groups received unplanned triage-based screening. The prevalence among these "no-risk" patients who fell outside the 1945-1965 birth cohort and were not known to be injection drug users was significantly lower, at 2.6%. The report did not mention sexual transmission of HCV, which is known to occur especially among HIV-positive gay and bisexual men.

HCV screening outside the protocol occurred in part because triage nurses were uncomfortable asking patients about their injection drug use in a non-private setting, and would have preferred universal HCV screening. In addition, the researchers suggested some patients may refuse testing because they feel stigmatized when the screening protocol includes questions about drug use. This led them to consider adopting an ED policy of non-targeted HCV screening, but the CDC has not set a minimum HCV screening prevalence threshold (as it has for universal HIV testing), and testing outside of the recommended birth cohort and risk groups may not be reimbursable.

"Given skyrocketing rates of injection heroin use around the country, we expect the already high rates of hepatitis C infection to explode," White said in an Annals of Emergency Medicinepress release. "Intervention by emergency departments, in the form of screening and referral for treatment, could help slow the spread of this potentially deadly, communicable disease…We have a better than even chance of reaching many of the 3 million people who are infected since they tend to be heavy emergency department users already. It gives us a chance to connect these people to ongoing care at HCV clinics or elsewhere in the health care system."

9/9/15

Reference

DAE White, ES Anderson, SK Pfeil, et al. Results of a Rapid Hepatitis C Virus Screening and Diagnostic Testing Program in an Urban Emergency Department. Annals of Emergency Medicine. August 4, 2015 (online ahead of print).

Other Source

Annals of Emergency Medicine. Urban ERs See High Rates of Hepatitis C Infection. Press release. August 6, 2015.