Urban ED Screening Finds High Rates of Hepatitis C

Larry Beresford

August 11, 2015

A new study published online August 4 in the Annals of Emergency Medicine has confirmed high rates of hepatitis C infection among users of an urban emergency department (ED). Patients at high risk were not just those known to be intravenous drug users but also the birth cohort of Baby Boomers, who were born between 1945 and 1965.

The Centers for Disease Control and Prevention (CDC) currently estimates that about 2.7 million Americans are infected with the hepatitis C virus (HCV). However, previous studies indicate that many are unaware of their status.

Whereas intravenous drug use is the leading risk factor for HCV, Baby Boomers have been identified as another high-risk cohort, with national infection rates of 3% to 4%. As previously reported by Medscape Medical News, the CDC currently recommends one-time screening for the virus for Baby Boomers.

Douglas A. E. White, MD, emergency physician and director of education, and colleagues at the Alameda Health System, Highland Hospital, Oakland, California, conducted a retrospective analysis of antibody results among ED patients who completed an offered test for the virus. The hospital, which serves a racially and ethnically diverse patient population, initiated a screening program in April 2014 that followed CDC recommendations, with triage nurses offering the test to participants who reported injection drug use or who were born between 1945 and 1965.

Of 26,639 unique adult admissions to the hospital's ED between April 17 and October 31, 2014, 7554 were offered the screening according to protocols, 3285 accepted it, and 2581 (9.7% of unique adult admissions) completed it.

Of those tested, 267 (10.3%) patients were found to be positive for hepatitis C, most of whom were chronically infected. Only 64 (24%) of the patients who were HCV-positive were aware of their infection.

Although injection drug users had the highest risk for a positive test (38.4% prevalence; odds ratio [OR], 10.8; 95% confidence interval [CI], 7.5 - 15.5), those who were homeless (25.5% prevalence; OR 3.1; 95% CI, 1.5 - 6.8), underwent diagnostic testing (14.8% prevalence; OR, 2.6; 95% CI, 1.7 - 3.9), fell in the Baby Boomer birth cohort (13.7% prevalence; OR, 3.6; 95% CI, 2.4 - 5.3), or were male (12.4% prevalence; OR, 1.4; 95% CI, 1.0 - 2.0) also had increased risk.

The researchers say that triage nurses at the hospital often deviated from the protocol, failing to ask about injection drug use or offering the screening to patients outside of the birth cohort. But for those who tested positive, staff members often arranged follow-up clinic appointments. Specifically, 180 (67%) underwent confirmatory testing, and 126 (70%) of those were positive; staff arranged follow-up appointments for 57 (45%) of those who had confirmed positive tests.

The authors note that staff also tested 613 patients who did not meet the screening guidelines. Among those patients, the rate of infection was 2.6%.

"[U]rban [EDs] may play an important role as safety net providers for HCV screening," Dr White said in a news release. "We have a better than even chance of reaching many of the three million people who are infected, since they tend to be heavy [ED] users already. It gives us a chance to connect these people to ongoing care at HCV clinics or elsewhere in the health care system."

Dr White and one coauthor report grants from Gilead Sciences during the conduct of this study. The other authors have disclosed no relevant financial relationships.

Ann Emerg Med. Published online August 4, 2015. Full text

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