Routine Screening of Emergency Admissions at Risk of Chronic Hepatitis (SEARCH) Identifies and Links Hepatitis B Cases to Care

Rachael Jacob; David S. Prince; Joseph L. Pipicella; Angela Nguyen; Melissa Bagatella; Frank Alvaro; Michael Maley; Hong Foo; Paul Middleton; Tahrima Kayes; Julia DiGirolamo; Scott A. Davison; Miriam T. Levy


Liver International. 2023;43(1):60-68. 

In This Article

Abstract and Introduction


Background and Aims: Significant barriers exist with hepatitis B (HBV) case detection and effective linkage to care (LTC). The emergency department (ED) is a unique healthcare interaction where hepatitis screening and LTC could be achieved. We examined the efficacy and utility of automated ED HBV screening for Overseas Born (OB) patients.

Methods: A novel-automated hepatitis screening service "SEARCH" (Screening Emergency Admissions at Risk of Chronic Hepatitis) was piloted at a metropolitan hospital. A retrospective and comparative analysis of hepatitis testing during the SEARCH pilot compared to a period of routine testing was conducted.

Results: During the SEARCH pilot, 4778 OB patients were tested for HBV (86% of eligible patient presentations), compared with 1.9% of eligible patients during a control period of clinician-initiated testing. SEARCH detected 108 (2.3%) hepatitis B surface antigen positive patients including 20 (19%) in whom the diagnosis was new. Among 88 patients with known HBV, 57% were receiving medical care, 33% had become lost to follow-up and 10% had never received HBV care. Overall, 30/88 (34%) patients with known HBV were receiving complete guideline-based care prior to re-engagement via SEARCH. Following SEARCH, LTC was successful achieved in 48/58 (83%) unlinked patients and 19 patients were commenced on anti-viral therapy. New diagnoses of cirrhosis and hepatocellular carcinoma were made in five and one patient(s) respectively.

Conclusions: Automated ED screening of OB patients is effective in HBV diagnosis, re-diagnosis and LTC. Prior to SEARCH, the majority of patients were not receiving guideline-based care.


Hepatitis B (HBV) is a global public health challenge with chronic infection leading to cirrhosis and hepatocellular carcinoma (HCC). Early diagnosis and antiviral therapy (AVT) are fundamental to reducing liver-related morbidity and mortality.[1] The World Health Organisation (WHO) prioritises HBV, aiming to reduce mortality by 65% by 2030.[1] Such an ambitious goal will require significant public health innovation.[2] Hepatitis C (HCV) micro-elimination strategies in prison and in persons who inject drugs (PWID) have been efficacious.[3,4] Micro-elimination strategies for HBV will differ and require consideration of where these patients are most likely to be found epidemiologically.

The Australian healthcare system delivers high rates of HBV vaccination and excellent maternal and perinatal care; however, gaps exist in diagnosis and linkage to care (LTC) of people with existing chronic infection.[5] Whilst the Australian National Testing Policy endorses testing priority populations, including those born in high prevalence countries and Aboriginal or Torres Strait Islander (ATSI) peoples,[6] the uptake remains poor. It is estimated that up to 30% of HBV-infected individuals remain undiagnosed in Australia.[6]

The majority of people living with chronic HBV in Australia are overseas born (OB).[5] Many acquired the infection in childhood and may be unaware of their status. Those from culturally and linguistically diverse backgrounds (CALD) face barriers engaging with health promotion material but do attend the emergency department (ED) as necessary.[7] Hence, the ED represents a potential opportunity to engage.

It has been shown that screening for chronic HBV is cost-effective, particularly in high-risk populations.[8–10] Universal screening is accepted in obstetric populations and could be implemented in other populations when aligned with the National Testing Policy. A call for universal HBV testing in Australia has been made to reduce complexity in decision making,[11] however, barriers to implementation will remain. Despite policy, healthcare workers may fail to implement screening, as the patient's presenting healthcare concern often takes priority. We considered the ED to be a place where an automated and universal approach could be implemented for testing the target population.

This study aims to assess the Screening of Emergency Admissions at Risk of Chronic Hepatitis (SEARCH) pilot—efficacy (testing rates) and utility (infection rates and LTC) of automated ED screening in OB patients and compare this to a period of routine clinician-initiated testing. During the pilot service, patient selection by their demographics triggered hepatitis testing utilising serum samples already collected as part of their health care assessment in the ED. A cost analysis was also performed to describe the total actual costs of this pilot service. It also aimed to report the cost per patient tested and per hepatitis B surface antigen (HBsAg) positive patient identified.