Integrating Hepatitis C Virus Screening of Baby Boomers at a Community Hospital Emergency Department

Gregory Wu; Aiqi Zhou; Steve Kwon


J Viral Hepat. 2022;29(4):263-270. 

In This Article

Abstract and Introduction


Approximately 2.4 million Americans are infected with hepatitis C virus (HCV), and persons born from 1945 through 1965 (i.e. baby boomers) account for nearly three-fourths of all HCV infections. The purpose of this study was to implement HCV screening for baby boomers presenting to a community hospital emergency department (ED) and to facilitate linkage to care. We developed a process within our electronic medical record system to screen patients for HCV testing eligibility, link eligible patients to laboratory orders, notify patients of HCV test results (via patient navigator) and track follow-up care. We tracked performance from February 2016 to December 2018. Sociodemographic compositions and linkage to care rates of all participants were evaluated. A total of 14,927 patients from the birth cohort of 1945–1965 were screened for HCV. Of those tested, 555 (3.7%) had a positive HCV antibody test and 147 were HCV RNA-positive patients (1.0%) demonstrating that only 27% of HCV antibody-positive individuals were chronically infected. Males, black race and USA-born baby boomers had a higher prevalence of HCV antibody and viral load positivity (p < 0.05). Initially, only 17.6% of patients were ultimately linked to care, which improved to over 94% after the implementation of patient navigation support. There is a need for HCV screening protocol in the community. The cost of implementing an HCV screening programme must include information technology and a team of care coordinators to improve screening rates and facilitate linkage to continual care using the four pillars framework.


There are an estimated 2.4 million hepatitis C virus (HCV)-infected persons in the USA, and about 50%–75% of all infected people are unaware that they are infected.[1,2] Advances in treatment regimens for HCV will have limited impact on HCV-related morbidity and mortality without early detection of infected persons and concomitant improvement in linkage to care (LTC). While advances in HCV treatment can now cure more than 90% of chronically infected persons using short-term and well-tolerated regimens,[3–6] many are diagnosed with advanced liver disease. In the USA, it is estimated that only 12%–18% of the total HCV-infected population has undergone disease staging with liver biopsy and that an even smaller proportion of 7%–11% of the total HCV-infected population had received treatment by 2013.[7] This presents an important public health opportunity to reduce HCV-related morbidity and mortality.

The Centers for Disease Control and Prevention (CDC) estimated that persons in the 1945 to 1965 birth cohort (i.e. baby boomers) accounted for nearly three-fourths of all HCV infections in the USA, which accounts for five-times higher prevalence (3.25%) than other adults.[8] This birth cohort also accounted for 73% of HCV-associated mortality having the greatest risk for HCV-related liver disease and hepatocellular carcinoma.[8] A retrospective review showed that while only 27% of persons with HCV infection would have been identified through a risk-based approach, about 68% of persons with HCV infection would have been identified through a birth cohort testing strategy.[9] Accordingly, in 2012, CDC expanded its guidelines originally issued in 1998 with a recommendation to offer a one-time test to all persons born from 1945 through 1965, without prior ascertainment of HCV risk factors. At the time of this study, the US Preventive Services Task Force (USPSTF) also recommended that a one-time test be done in an asymptomatic person belonging to the 1945–1965 birth cohort.

Studies have suggested implementing clinical decision support tools or prompts for HCV testing in electronic health records that can help facilitate HCV testing when indicated.[10,11] Emergency department (ED) plays an important role in population-based HCV screening because it has been shown that patients without a regular source of care (i.e. primary care) are 19 times more likely to be unaware of their HCV infection and the ED can often act as the main source of care of 'difficult-to-access' patients.[12] Most studies reporting their experiences with implementing HCV screening in the emergency department have come from large urban EDs and academic institutions.[13–16] Limited studies are available that describe the impact of implementing HCV screening programmes at ED sites in the community outside the large urban settings. In this paper, we report the proportion of patients screened using an opt-in approach of the baby-boomer birth cohorts, describe characteristics of screened, HCV-positive and HCV viral load-positive patients and analyse the cross-sectional prevalence of those who were screened that tested positive for HCV antibody and HCV viral load.