Unrecognized chronic hepatitis C virus infection among baby boomers in the emergency department

Abstract

The Centers for Disease Control and Prevention and U.S. Preventive Services Task Force have highlighted public screening as an essential strategy for increasing hepatitis C virus (HCV) detection in persons born between 1945 and 1965 ("baby boomers"). Because earlier HCV screening efforts have not targeted emergency department (ED) baby boomer patients, we describe early experience with integrated opt-out HCV antibody (Ab) screening of medically stable baby boomers presenting to an urban academic ED. We performed HCV Ab testing 24 hours per day and confirmed positive test results using polymerase chain reaction (PCR). The primary outcome was prevalence of unrecognized HCV infection. Among 2,325 unique HCV-unaware baby boomers, 289 (12.7%) opted out of HCV screening. We performed HCV Ab tests on 1,529 individuals, of which 170 (11.1%) were reactive. Among Ab reactive cases, follow-up PCR was performed on 150 (88.2%), of which 102 (68.0%) were confirmed RNA positive. HCV Ab reactivity was more likely in males compared to females (14.7% vs. 7.4%; P < 0.001), African Americans compared to whites (13.3% vs. 8.8%; P 5 0.010), and underinsured/ uninsured patients compared to insured patients (16.8%/16.9% vs. 5.0%; P 5 0.001). Linkage-to-care service activities were recorded for 100 of the 102 confirmed cases. Overall, 54 (54%) RNA-positive individuals were successfully contacted by phone within five call-back attempts. We confirmed initial follow-up appointments for 38 (70.4%) RNA-positive individuals successfully contacted, and 21 (55.3%) individuals with confirmed appointments attended their initial visit with a liver specialist; 3 (7.9%) are awaiting an upcoming scheduled appointment. Conclusion: We observed high prevalence of unrecognized chronic HCV infection in this series of baby boomers presenting to the ED, highlighting the ED as an important venue for high-impact HCV screening and linkage to care. (HEPATOLOGY 2015;61:776-782) C hronic hepatitis C virus (HCV) infection is an urgent public health challenge in the United States, affecting an estimated 5.2 million individuals.1 Sequelae of untreated chronic HCV infection, such as cirrhosis and hepatocellular carcinoma, are common (2%-30%), and rates of these complications are expected to rise.2,3 A recent surge in the number of highly effective direct-acting agents has transformed the care of HCV infection, highlighting the urgency of identifying persons with this condition. 4,5As a result of the expansion of illicit drug use and contaminated transfusions that occurred in the 1970s and 1980s, HCV infection is particularly prevalent in the "baby boomer" population (those born between 1945

Detecting Hepatitis B and C by Combined Public Health and Primary Care Birth Cohort Testing

“…Higher positive rates and lower numbers needed to screen to detect 1 case have been found in birth cohort studies in higher prevalence settings and countries, such as the United States. 15,26,37,42 Detected positive rates were higher in those with a hepatitis exposure risk factor, a finding in line with studies targeting risk factors. 15,26 Using a risk group instead of the birth cohort, however, would have missed 22% to 54% of all positive cases in this study (3 of 7 anti-HCV-positive cases, 2 of 9 HBsAg-positive cases, and 77 of 142 anti-HBc-positive cases).…”

“…[29][30][31][32][33][34][35][36] The family physicians' personal invitation appeared key for achieving this high uptake, as confirmed by the reported main reason to get tested. Test uptake in specific settings, such as the emergency department, may be even higher (up to 65%), 37 as here tests can be offered and performed within the routine diagnostic work-up.…”

Results of a Rapid Hepatitis C Virus Screening and Diagnostic Testing Program in an Urban Emergency Department

“…During a 6-week period, their triage staff screened 85% of the eligible birth cohort and performed 1,529 tests, of which 170 were positive (prevalence 11%). 13 We found similarly high rates of hepatitis C virus among screened baby boomers (prevalence 14%). In addition to birth cohort screening, our program included hepatitis C virus screening for patients who use injection drugs (prevalence 38%), as well as those who completed physician diagnostic hepatitis C virus testing (prevalence 15%).…”

“…Challenges encountered with hepatitis C virus screening included result disclosure, confirmatory testing, and linkage to care. We add to work by Galbraith et al, 13 who screened baby boomers in an academic urban ED, and report our experience with hepatitis C virus screening targeting patients with a history of injection drug use, in addition to the birth cohort. We believe our findings highlight the burden of hepatitis C virus infection among patients receiving care in an urban ED, demonstrate the critical role EDs may serve in identifying patients with undiagnosed hepatitis C virus infection, and call attention to the resources necessary to support efforts to develop and evaluate policies for ED-based hepatitis C virus screening and diagnostic testing.…”

“…[9][10][11][12] Although clinical experience is limited, one recent study showed that ED birth cohort screening is feasible and high yield, with a reported prevalence of 11%. 13 In April 2014, we implemented an ED-based screening program for both HIV and hepatitis C virus into our triage processes according to CDC and US Preventive Services Task Force recommendations. 4,5 As an adjunct to screening, physicians could order HIV and hepatitis C virus diagnostic testing when clinically indicated.…”