Locations and Reasons for Initial Testing for Hepatitis C Infection

Chronic Hepatitis Cohort Study, United States, 2006-2010

Joseph A. Boscarino, PhD; Stuart C. Gordon, MD; Loralee B. Rupp, MBA; Mark A. Schmidt, PhD; Vinutha Vijayadeva, MBBS; Anne Moorman, MPH; Fujie Xu, MD; Scott D. Holmberg, MD; Stephen C. Ko, MD


Morbidity and Mortality Weekly Report. 2013;62(32):645-648. 

In This Article


Chronic hepatitis C virus (HCV) infection causes substantial morbidity and mortality in the United States.[1] Testing and treatment of asymptomatic persons might avert progression to more advanced disease. In 1998, CDC published guidelines for HCV testing based on risk factors for infection; however, recent studies indicate that at least one half of all persons living with HCV infection in the United States are unaware of their infection status.[2–4] To increase testing rates, in 2012 CDC recommended one-time testing of all persons born during 1945–1965.[5] To better understand where and why persons with chronic HCV infection sought their initial testing, 2006–2010 data were analyzed from a survey conducted as part of the ongoing Chronic Hepatitis Cohort Study.[6] Of 4,689 patients with HCV infection who responded to the survey, 60.4% reported that their initial HCV test occurred in a physician's office. CDC's risk-based indications (e.g., injection drug use and hemodialysis) were cited by 1,045 (22.3%) of the patients as reasons for testing, whereas clinical indications (e.g., abnormal liver function tests or liver-related symptoms such as jaundice) were cited by 2,121 (45.2%), suggesting that many HCV infections were identified only after the patient had become symptomatic. Promoting U. S. Preventive Services Task Force[7] and CDC recommendations for testing[5] and identifying strategies that help physicians implement HCV testing in their offices might help facilitate timely identification of HCV infection and reduce morbidity and mortality.

The Chronic Hepatitis Cohort Study follows patients with confirmed chronic HCV or hepatitis B virus infection who receive care at four integrated health-care systems in the United States:[3,6] Geisinger Health System, Danville, Pennsylvania; Henry Ford Health System, Detroit, Michigan; Kaiser Permanente Hawaii, Honolulu, Hawaii; and Northwest Permanente, Portland, Oregon. Of 12,529 patients aged ≥18 years who met the inclusion criteria for confirmed chronic HCV infection,[6] 10,380 (82.8%) were sampled randomly for the current analysis. After excluding 1,451 patients who died and 828 who could not be contacted because of an invalid telephone number or address, incarceration, long-term care, or because of a physician's request that contact should not be made, the remaining 8,101 (64.7%) patients were surveyed by U.S. mail or telephone during 2011–2012. Up to eight telephone contact attempts were made; a small incentive was offered to encourage participation. The study protocol was reviewed and approved by an institutional review board approved by the federal Office for Human Research Protections at each participating site.

The survey was designed to collect data regarding the location and reasons for initial HCV testing. Participants were asked to choose from a list of reasons for HCV testing. Their responses were then grouped and analyzed in four categories: 1) CDC risk indications, according to the 1998 guidelines for testing (e.g., injection drug use and hemodialysis); 2) clinical indications (e.g., abnormal liver function tests or liver-related symptoms such as jaundice or abdominal pain); 3) institutional requirements (e.g., from blood banks, insurance or health maintenance organizations, prison, work/school, or the military); and 4) other miscellaneous reasons, including a doctor recommendation, "thought I was exposed," spouse's recommendation, foreign-born (from a country where hepatitis is endemic), and sexual contact with an HCV-infected person. Reasons for testing were not mutually exclusive; patients could choose more than one reason.

Of the 8,101 patients contacted, 4,689 (57.9%) completed the survey. Compared with nonrespondents, survey participants were slightly older (mean age: 57.4 years compared with 56.9 years, p=0.003), more likely to be white (72.8% compared with 61.4%, p<0.001), and more likely to be women (43.9% compared with 38.0%, p<0.001).

Of the 4,689 participants, 3,663 (78.1%) were born during 1945–1965; 87.4% had a high school diploma or its equivalent; 98.1% had insurance; 45.5% were employed; and 23.2% received disability payments (Table 1). Most respondents (60.4%) reported receiving the HCV test in a physician's office (Table 2). For those born during 1945–1965: 62.1% were tested in physicians' offices, 9.4% in blood banks or at blood drives, 7.4% in public health or specialty clinics, and 5.4% in inpatient settings (Table 2). For those born before 1945 or after 1965, a smaller proportion (54.3%) of tests occurred in physicians' offices, whereas testing in clinics (11.9%) and inpatient settings (7.5%) constituted larger proportions.

The 4,689 participants reported 7,649 reasons for their initial HCV test. Of the total, 3,473 responses (45.4%) were "miscellaneous reasons" not included in CDC's risk indications for testing (Table 3).

Among the 4,689 survey participants, clinical indications were reported by 2,121 (45.2%) as a reason for testing and CDC risk indications by 1,045 (22.3%). Among the 1,045 participants citing CDC risk indications, 986 (94.4%) reported injection drug use. Institutional requirements were reported by 781 (16.7%), and doctor-recommended testing was reported by 1,725 (36.8%) participants (Table 3).

For the 3,663 participants born during 1945–1965, clinical indications were cited by 1,713 (46.8%) participants, with 781 (21.3%) reporting CDC risk indications as a reason for their initial HCV test. Among those born during 1945–1965, institutional requirements were reported as a reason by 638 (17.4%), and 1,319 (36.0%) reported doctor recommendations as a reason for testing (Table 3).