Nontargeted Hepatitis C Screening in an Urban Emergency Department in New York City

Hepatitis C testing and linkage to care in a safety-net hospital emergency department

BACKGROUND AND PURPOSE

In 2020, the CDC expanded hepatitis C (HCV) screening recommendations to include universal screening for persons 18 and older. We implemented universal screening in the emergency department (ED) within a safety-net health system. We aimed to measure HCV prevalence and linkage to care (LTC) outcomes in the ED and compare them to the outpatient clinics within the same health system.

METHODS

Patients aged 18-79 without HCV qualified for screening. We measured prevalence of both anti-HCV+ (exposure) and HCV RNA+ (active infection). Those with active HCV were flagged for LTC and their charts were followed for outcomes. HCV prevalence and LTC in the ED were compared to those in outpatient clinics over the same time.

RESULTS

9511 patients were screened for HCV from 2019 to 2022 in the ED. 6.9 % (659) were anti-HCV+. 54.9 % (320 of 582) of anti-HCV+ individuals or 3.4 % of those screened (320 of 9511) were HCV RNA+. The LTC rate was 24.1 % (77 of 320) and a total of 56 individuals (17.8 % of all HCV RNA+ ED patients, 72.7 % of those linked) initiated treatment. HCV prevalence was higher in the ED compared to the outpatient clinic setting. Demographics and LTC rates also significantly differed between these two cohorts.

CONCLUSIONS

We identified a higher HCV prevalence in the ED relative to the outpatient clinic setting and significant need for improvement in LTC and HCV treatment initiation. Our findings suggest universal screening is an important tool to diagnose HCV infections but may require novel strategies for improved LTC and treatment initiation.

Enhancing Hepatitis C Virus Testing, Linkage to Care, and Treatment Commencement in Hospitals: A Systematic Review and Meta-analysis

Background

The hospital-led interventions yielding the best hepatitis C virus (HCV) testing and treatment uptake are poorly understood.

Methods

We searched Medline, Embase, and Cochrane databases for studies assessing outcomes of hospital-led interventions for HCV antibody or RNA testing uptake, linkage to care, or direct-acting antiviral commencement compared with usual care, a historical comparator, or control group. We systematically reviewed hospital-led interventions delivered in inpatient units, outpatient clinics, or emergency departments. Random-effects meta-analysis estimated pooled odds ratios [pORs] measuring associations between interventions and outcomes. Subgroup analyses explored outcomes by intervention type.

Results

A total of 7872 abstracts were screened with 23 studies included. Twelve studies (222 868 participants) reported antibody testing uptake, 5 (n = 4987) reported RNA testing uptake, 7 (n = 3185) reported linkage to care, and 4 (n = 1344) reported treatment commencement. Hospital-led interventions were associated with increased antibody testing uptake (pOR, 5.83 [95% confidence interval {CI}, 2.49-13.61]; I 2 = 99.9%), RNA testing uptake (pOR, 10.65 [95% CI, 1.70-66.50]; I 2 = 97.9%), and linkage to care (pOR, 1.75 [95% CI, 1.10-2.79]; I 2 = 79.9%) when data were pooled and assessed against comparators. Automated opt-out testing (5 studies: pOR, 16.13 [95% CI, 3.35-77.66]), reflex RNA testing (4 studies: pOR, 25.04 [95% CI, 3.63-172.7]), and care coordination and financial incentives (4 studies: pOR, 2.73 [95% CI, 1.85-4.03]) showed the greatest increases in antibody and RNA testing uptake and linkage to care, respectively. No intervention increased uptake at all care cascade steps.

Conclusions

Automated antibody and reflex RNA testing increase HCV testing uptake in hospitals but have limited impact on linkage to treatment. Other interventions promoting linkage must be explored.

Global Elimination of Hepatitis C Virus

Hepatitis C virus (HCV) is predominantly transmitted through parenteral exposures to infectious blood or body fluids. In 2019, approximately 58 million people worldwide were infected with HCV, and 290,000 deaths occurred due to hepatitis C-related conditions, despite hepatitis C being curable. There are substantial barriers to elimination, including the lack of widespread point-of-care diagnostics, cost of treatment, stigma associated with hepatitis C, and challenges in reaching marginalized populations, such as people who inject drugs. The World Health Organization (WHO) has set goals to eliminate hepatitis C by 2030. Several countries, including Australia, Egypt, Georgia, and Rwanda, have made remarkable progress toward hepatitis C elimination. In the United States, the Biden-Harris administration recently issued a plan for the national elimination of hepatitis C. Global progress has been uneven, however, and will need to accelerate considerably to reach the WHO's 2030 goals. Nevertheless, the global elimination of hepatitis C is within reach and should remain a high public health priority.

Factors Associated with Take Home Naloxone Refusal among Emergency Department Patients Participating in an Opioid Overdose Prevention Program

BACKGROUND

Increasing the equitable distribution of take home naloxone (THN) may result in reduced deaths from opioid overdose (OD).

OBJECTIVES

The primary study objective is to describe the demographic and clinical characteristics of emergency department (ED) patients who decline THN. The findings of this descriptive study may generate new hypotheses for successful THN distribution.

METHODS

Retrospective chart review using prospectively collected program evaluation data from a single urban EDs Health Education THN database and electronic health record. Characteristics of participants who refused versus accepted THN were compared using Chi-square testing for categorical variables and t-tests for continuous variables. A multivariate model was built to assess associations of statistical and clinically relevant characteristics with THN refusal.

RESULTS

A total of 711 ED patients were offered THN of which 334 (46%) declined. In unadjusted analysis, with the independent variable being refusal of the THN offer, being currently on medication for opioid use disorder (MOUD) was associated with a greater odds of refusal (OR 1.9, 95%CI 1.3-2.6) while any drug related overdose (OR 0.6, 95%CI 0.4-0.8) or being given a prescription for buprenorphine in the ED (OR 0.2, 95%CI 0.1-0.9) were both associated with a lower odds of refusal.

CONCLUSIONS

Demographic characteristics did not differ between those who accept versus refuse THN. Patients already receiving MOUD were more likely to refuse THN while those starting MOUD in the ED were less likely to refuse THN. Further studies are needed to determine the root causes of patients' declination of THN and develop targeted interventions to address these causes.

Birth cohort-specific consideration in an Emergency Department Hepatitis C Testing Programme: A description of age-related characteristics and outcomes

The emergency department (ED) has increasingly become an important public health partner in non-targeted hepatitis C virus (HCV) testing and referral to care efforts. HCV has traditionally been an infection associated with the Baby Boomer generation; however, recent exacerbation of the opioid epidemic has resulted in a growing number of younger cohorts, namely Millennials, also impacted by HCV. Examination of this age-related demographic shift, including subsequent linkage success and linkage barriers, from the perspective of an ED-based testing and linkage programme may have implications for future population and health systems interventions. A retrospective descriptive chart review was performed, inclusive of data from August 2015 through December 2020. We compared the quantity of positive HCV screening antibody (Ab) and confirmatory (RNA) tests and further considered linkage rates and correlative demographics (e.g. gender, race). Patient barriers to HCV care linkage (e.g. substance misuse, lack of health insurance, homelessness) were also evaluated. The data set was disaggregated by birth cohort to include Silent Generation (SG) (1928-45), Baby Boomer (BB) (1946-64), Generation X (Gen X) (1965-80), Millennial (1981-96) and Generation Z (1997-2012). Descriptive statistics and chi-square analysis were performed. Overall, 83,817 patients were tested for HCV (50.6% of eligible); 6187 (7.4%) were HCV Ab positive, and 2665 were HCV RNA positive (3.2%). RNA-positive individuals were more likely to be white (70.4%) and male (67.7%); generational distribution was similar (BB 33.3%, Gen X 32.0% and Millennials 32.7%). Amongst Ab-positive patients, white (45.5%), male (47.2%) and Millennial (49.7%) individuals were most likely to be RNA-positive. Overall, 28.1% of the RNA-positive cohort successfully linked to care; linkage to care rates were significantly higher in older generations (38.1% in BB vs. 17.8% in Millennials) (p < .00001). Over 90% were identified as having at least one linkage to care barrier. Younger generations (Gen X and Millennials) were disproportionately impacted by linkage barriers, including incarceration, lack of health insurance, history of mental health and substance use disorders, as well as history of or active injection drug use (IDU) (p < .00001). Older generations (SG and BB) were more likely to be impacted by competing medical comorbidities (p < .00001). The ED population represents a particularly vulnerable, at-risk cohort with a high prevalence of HCV and linkage to care barriers. While past HCV-specific recommendations and interventions have focused on Baby Boomers, this data suggests that younger generations, including Gen X and Millennials, are increasingly affected by HCV and face disparate social risk and social need factors which impede definitive care linkage and treatment.

Relationship of hepatitis C risk to hepatitis C test acceptance among adult patients participating in an ED hepatitis C screening programme

BACKGROUND

It is possible that adult ED patients consider their hepatitis C virus (HCV) risk factor history when deciding whether to accept HCV screening. To help address this question, we examined whether self-reporting any HCV risk was more common among ED patients who agreed than who declined HCV screening. Among ED patients who agreed to HCV screening, we also assessed if self-reporting any HCV risk was more common among those whose HCV antibody (Ab) and HCV viral load (VL) test results were positive.

METHODS

This study was conducted among adult patients ≥18 years old participating in a universal, ED-based HCV screening programme in New York City between 22 January 2019 and 9 April 2020. Participants were surveyed about their HCV risk factors. Differences in the frequencies of self-reporting any HCV risk were compared according to HCV screening acceptance and by HCV Ab and VL status.

RESULTS

Of the 4658 ED patients surveyed, 2846 (61%) accepted and 1812 (39%) declined HCV screening. Among these participants, 38% reported at least one HCV risk factor, most commonly injection drug use. Self-reporting any HCV risk was not more common among those who accepted versus declined HCV screening (40% vs 37%, p<0.7) but was more common among those with HCV Ab positive versus negative test results (36% vs 6%, p<0.001) and HCV VL positive versus negative results (95% vs 5%, p<0.001).

CONCLUSION

HCV risk factors were self-reported by more than one-third of ED patients but were not more commonly present among those who accepted HCV screening.

Universal testing for hepatitis B and hepatitis C in the emergency department: a cost-effectiveness and budget impact analysis of two urban hospitals in the United Kingdom

Background

Numerous studies have shown the effectiveness of testing for hepatitis B (HBV) and hepatitis C (HCV) in emergency departments (ED), due to the elevated prevalence amongst attendees. The aim of this study was to conduct a cost-effectiveness analysis of universal opt-out HBV and HCV testing in EDs based on 2 long-term studies of the real-world effectiveness of testing in 2 large ED’s in the UK.

Methods

A Markov model was used to evaluate ED-based HBV and HCV testing versus no ED testing, in addition to current testing practice. The two EDs had a HBV HBsAg prevalence of 0.5–0.9% and an HCV RNA prevalence of 0.9–1.0%. The analysis was performed from a UK health service perspective, over a lifetime time horizon. Costs are reported in British pounds (GBP), and outcomes as quality adjusted life years (QALYs), with both discounted at 3.5% per year. Incremental cost-effectiveness ratios (ICER) are calculated as costs per QALY gained. A willingness-to-pay threshold of £20,000/QALY was used. The cost-effectiveness was estimated for both infections, in both ED’s.

Results

HBV and HCV testing were highly cost-effective in both settings, with ICERs ranging from £7,177 to £12,387 per QALY gained. In probabilistic analyses, HBV testing was 89–94% likely to be cost-effective at the threshold, while HCV testing was 94–100% likely to be cost-effective, across both settings. In deterministic sensitivity analyses, testing remained cost-effective in both locations at ≥ 0.25% HBsAg prevalence, and ≥ 0.49% HCV RNA prevalence. This is much lower than the prevalence observed in the two EDs included in this study.

Conclusions

HBV and HCV testing in urban EDs is highly cost-effective in the UK, and can be cost-effective at relatively low prevalence. These results should be reflected in UK and European hepatitis testing guidelines.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12962-022-00388-7.

Risk factors for hepatitis C virus infection at a large urban emergency department

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.

Sustained Impact of the Coronavirus Disease 2019 Pandemic on Hepatitis C Virus Treatment Initiations in the United States

BACKGROUND

Recent reports indicated declines in hepatitis C virus (HCV) testing during the first half of 2020 in the United States due to coronavirus disease 2019 (COVID-19), but the longer-term impact on HCV testing and treatment is unclear.

METHODS

We obtained monthly state-level volumes of HCV antibody, RNA and genotype testing, and HCV treatment initiation, stratified by age and gender, spanning January 2019 until December 2020 from 2 large national laboratories. We performed segmented regression analysis for each state from a mixed-effects Poisson regression model with month as the main fixed predictor and state as a random intercept.

RESULTS

During the pre-COVID-19 period (January 2019-March 2020), monthly HCV antibody and genotype tests decreased slightly whereas RNA tests and treatment initiations remained stable. Between March and April 2020, there were declines in the number of HCV antibody tests (37% reduction, P < .001), RNA tests (37.5% reduction, P < .001), genotype tests (24% reduction, P = .023), and HCV treatment initiations (31%, P < .001). Starting April 2020 through the end of 2020, there were significant increases in month-to-month HCV antibody (P < .001), RNA (P = .035), and genotype tests (P = .047), but only antibody testing rebounded to pre-COVID-19 levels. HCV treatment initiations remained low after April 2020 throughout the remainder of the year.

CONCLUSIONS

HCV testing and treatment dropped by >30% during April 2020 at the start of the COVID-19 pandemic, but although HCV testing increased again later in 2020, HCV treatment rates did not recover. Efforts should be made to link HCV-positive patients to treatment and revitalize HCV treatment engagement by healthcare providers.

Birth cohort hepatitis C antibody prevalence in real-world screening settings in Ontario

BACKGROUND

Widespread screening and treatment of hepatitis C virus (HCV) is required to decrease late-stage liver disease and liver cancer. Clinical practice guidelines and Canadian Task Force on Preventative Health Care recommendations differ on the value of one-time birth cohort (1945-75) HCV screening in Canada. To assess the utility of this approach, we conducted a real-world analysis of HCV antibody (Ab) prevalence among birth cohort individuals seen in different clinical contexts.

METHODS

Cross-sectional study of individuals born between 1945 and 1975 who completed HCV Ab testing at multiple participating centres in Ontario, Canada between January 2016 and December 2020. Differences in prevalence were compared by year of birth, gender, and setting.

RESULTS

Among 16,672 birth cohort individuals tested, HCV Ab prevalence was 3.2%. Prevalence was higher among younger individuals which increased from 0.9% among those born between 1945 and 1956 to 4.6% among those born between 1966 and 1975. Prevalence was higher among males (4.4%) compared with females (2.0%) and differed by test site. In primary care, the prevalence was 0.5%, whereas the prevalence was highest among those tested at drug treatment centres (28.7%) and through community outreach (14.0%).

CONCLUSIONS

HCV Ab prevalence remains high in the 1945-1975 birth cohort. These data highlight the need to re-evaluate existing Canadian Preventative Task Force recommendations, to consider incorporating one-time birth cohort and/or other population-based approaches to HCV screening into the clinical workflow as a preventative health measure, and to increase training among community providers to screen for and treat HCV.