Risk Factors for Hepatitis C Virus Infection at a Large Urban Emergency Department

James S. Ford; Erika Hollywood; Bradley Steuble; Zichun Meng; Stephanie Voong; Tasleem Chechi; Nam Tran; Larissa May


J Viral Hepat. 2022;29(10):930-937. 

In This Article

Abstract and Introduction


In 2020, Centers for Disease Control and Prevention (CDC) released guidelines recommending HCV screening in all adults 18 years and older. In the current study, we aimed to identify risk factors for HCV infection in an ED population. We performed a retrospective analysis of ED patients ≥ 18 years who were screened for HCV between 28 November 2018, and 27 November 2019, at a single urban, quaternary referral academic hospital. An HCV-antibody immunoassay (HCV-Ab) was used for screening; positive results were confirmed by measuring HCV ribonucleic acid (RNA). The outcome of interest was the number of new HCV diagnoses (presence of viremia by HCV RNA testing). Multiple logistic regression models were used to identify risk factors associated with a new HCV diagnosis. 16,722 adult patients were screened for HCV (mean age: 46 ± 15 years; 51% female). HCV seroprevalence was 5%. Independent risk factors for HCV included increasing age [10-year aOR 1.26 (95% CI 1.23, 1.30)], male sex [aOR 1.25 (95% CI 1.03, 1.51)], undomiciled housing status [aOR 2.8 (95% CI 2.3, 3.5)], history of tobacco use [aOR 3.0 (95% CI 2.3, 3.9)], history of illicit drug use [aOR 3.6 (95% CI 2.9, 4.5)], Medicaid insurance status [aOR 4.0 (95% CI 2.9, 5.5)] and Medicare insurance status [aOR 1.6 (95% CI 1.1, 2.2)].The ED services a high-risk population with regards to HCV infection. These data support universal screening of ED patients for HCV. Risk factor profiles could improve targeted screening at institutions without universal testing protocols.



There are an estimated 184 million people that have been infected with hepatitis C virus (HCV) in the world.[1] In the United States (U.S.), HCV is the most common and deadliest blood-borne infection in the country, and the number of new acute HCV infections almost tripled between 2011 and 2019 (17,100 to 50,300).[2,3] As many as 85% of individuals with acute HCV will become chronically infected, predisposing them to the life-threatening consequences of cirrhosis and hepatocellular carcinoma.[3] The World Health Organization (WHO) has targeted an 80% global reduction in new chronic HCV infections by 2030.[4] To meet this goal, population-level HCV screening initiatives are needed. In 2019, the U.S. Preventative Service Task Force (USPSTF) released guidelines recommending HCV screening in all adults aged 18–79 years, and in 2020, the Centers for Disease Control and Prevention (CDC) released guidelines recommending HCV screening in all adults 18 years and older.[5,6]


The Emergency Department (ED) is an important safety net for underserved, high-risk populations, making it a vital setting to deliver healthcare services to patients without access to primary care.[7,8] Compelling evidence continues to emerge on the utility of ED-based infectious diseases screening programs, including those for Human Immunodeficiency Virus (HIV), Hepatitis B Virus (HBV) and Hepatitis C Virus (HCV).[8–13] Indeed, our group recently published a study that found high HCV antibody (Ab) and HCV RNA seropositivity in ED patients in a high-volume quaternary care academic centre with a large urban and rural catchment area.[14] Additionally, we demonstrated that a universal HCV screening protocol led to a large increase in HCV testing and new diagnoses.[14] While the results of these studies are encouraging and provide evidence that the ED setting services a high-risk population, the relatively low prevalence of HCV in the U.S. (Estimated prevalence: 1%), compared with high-endemic regions such as Central Asia (Estimated prevalence: 5.8%) and Central Sub-Saharan Africa (Estimated prevalence: 6.0%), makes population-level infection surveillance more difficult and more nuanced.[15,16] There is evidence to suggest that targeted and birth cohort-based ED-based screening programs may miss 25% of previously undiagnosed HCV cases when compared to universal HCV screening.[17] However, in settings where universal screening programs are unfeasible, tailoring testing strategies to target high-risk individuals has the potential to improve testing efficiency and reduce cost. One previous ED-based study examined risk factors for HCV-Ab seropositivity, and another ED-based study examined risk factors for HCV RNA positivity in the 1945–1965 birth cohort, but to our knowledge, no ED-based studies have examined risk factors for chronic HCV in a non-targeted adult population.[10,11]

Goals of This Investigation

In 2018, the study institution implemented an ED-based, universal HCV screening protocol. In the current study, we aimed to identify risk factors for confirmed HCV infection in an ED population, with the overall goal of tailoring future screening protocols to the risk profile of the local community.