Screening Emergency Admissions at Risk of Chronic Hepatitis C (SEARCH) to diagnose or 're-diagnose' infections is effective in Australia

The 'missing' in the 'endgame' of hepatitis C elimination: A qualitative study in New South Wales, Australia

INTRODUCTION

After a promising start in Australia, elimination efforts for hepatitis C are not on track. Following the global campaign to 'find the missing' in hepatitis C response, this qualitative study explores stakeholder perspectives on the 'missing' in the 'endgame' of hepatitis elimination in the state of New South Wales, Australia.

METHOD

Twenty-eight key informants working in New South Wales, elsewhere in Australia and internationally in high income countries participated in a semi-structured qualitative interview. Analysis examined key informant accounts of the 'missing' in efforts to eliminate hepatitis C.

RESULTS

Participants' accounts framed the missing in relation to epidemiological knowledge, making-up four population categories 'missing' or 'missed' in hepatitis C response. In turn, accounts situated the missing in relation to where and how individuals were presumed to connect, or not, with existing health-care infrastructures. This gave rise to concerns about the capacity of health services to be made available for those at risk or in need, with systems said to create opportunities for people to 'miss out' on hepatitis C services.

DISCUSSION AND CONCLUSIONS

The 'missing' in the 'endgame' of hepatitis C elimination effort is not simply a function of who-populations missed-but of where and how, that is, situation and context. Our findings encourage a focus on how services, systems and contexts may create situations in which people become missed or are 'made missing' from care. We therefore advocate for a systemic, and not only population-based, approach in the final push towards hepatitis C's elimination.

Routine screening of emergency admissions at risk of chronic hepatitis (SEARCH) identifies and links hepatitis B cases to care

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.

Finding Cases of Hepatitis C for Treatment Using Automated Screening in the Emergency Department is Effective, but What Is the Cost?

Case detection remains a major challenge for hepatitis C virus (HCV) elimination. We have previously published results from a pilot of an emergency department (ED) semiautomated screening program, SEARCH; Screening Emergency Admissions at Risk of Chronic HCV. Several refinements to SEARCH have been developed to streamline and reduce cost. All direct costs of HCV testing until direct-acting antiviral (DAA) therapy initiation were calculated. Cost was assessed in 2018 Australian Dollars. A cost analysis of the initial program and refinements are presented. Sensitivity analysis to understand impact of variation in staff time, laboratory test cost, changes in HCV antibody (Ab) prevalence, RNA positivity percentage, and rate of linkage to care was conducted. Impact of refinements (SEARCH (2)) to cost is presented. The total SEARCH pilot, testing 5000 patients was estimated to cost $110,549.52 (range $92,109.79-$129,581.24) comprising of $68,278.67 for HCV Ab testing, $21,568.99 for follow-up and linkage to care of positive patients and $20,701.86 to prepare HCV RNA positive patients for treatment. Internal program refinements resulted in a 25% cost reduction. Following refinements, the cost of HCV antibody screening was $8.46 per test and the total cost per positive HCV Ab, positive HCV RNA, and per treated patient were $611.77, $2,168.64, and $3,566.11, respectively. Our sensitivity analysis indicates costs per HCV case found are modest so long as HCV Ab prevalence was at least 1%. ED screening is an affordable strategy for HCV case detection and elimination.

Integrating hepatitis C virus screening of baby boomers at a community hospital emergency department

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.

Opt-out universal HCV and HIV screening in a Canadian emergency room: a cross-sectional study

OBJECTIVES

To determine the prevalence of undiagnosed hepatitis C virus (HCV) and HIV cases in a population sample tested in the emergency room (ER) and to evaluate linkage-to-care.

SETTING

Canadian university hospital.

PARTICIPANTS

Adults born after 1945 who consulted at ER for any condition and on any shift were included. Patients unable to opt-out were excluded.

INTERVENTIONS

ER nurse confirmed patients' eligibility and provided them with the option to opt-out. A physician met patients with a new diagnosis. Linkage-to-care was assessed 3 months postdiagnosis. Patients newly diagnosed with HCV were considered linked if they had an HCV RNA test, genotype, liver fibrosis evaluation, and if indicated, treatment prescription. Patients newly diagnosed with HIV were considered linked to care if they had an HIV serology confirmation test, viral load, CD4 cell count and started antiretroviral therapy.

PRIMARY AND SECONDARY OUTCOME MEASURES

Primary objective: to determine the prevalence (overall and undiagnosed cases) of HIV and HCV among the patients who consult the ER. Secondary objectives: to determine the proportion of patients who opt-out, assess the adherence of emergency staff to the offer of testing, determine the proportion of patients linked to care at 3 months.

RESULTS

Among 6350 eligible patients informed of the screening programme, 62.1% of patients were tested for at least one virus (HIV: 3905; HCV: 3910). 25% patients opted-out, 12% were not tested for organisational reasons, 0.3% (18) patients were HCV-HIV coinfected. Overall prevalence of HCV and HIV cases were 1.9% and 1.2%, respectively. Prevalence of new cases was 0.23% (95% CI 0.12% 0.45%) for HCV and 0.05% (95% CI 0.01% to 0.20%) for HIV. Among the new cases, only two HCV-infected and one HIV-infected patients were linked-to-care 3 months postdiagnosis.

CONCLUSIONS

Identification of new cases of HCV and HIV through universal screening at the ER and linkage-to-care were both low.

TRIAL REGISTRATION NUMBER

NCT03595527; Results.

Becoming posthuman: hepatitis C, the race to elimination and the politics of remaking the subject

Hepatitis C has long been a public health problem in Australia. 'Revolutionary' new drugs with the potential to cure hepatitis C have now emerged. The Australian government has invested heavily in them, and has an ambitious goal to eliminate hepatitis C by 2030. Numerous shifts in policy and practice are required if the elimination agenda is to be realised. This paper explores the significance of these shifts. We ask: what is the race to elimination doing with the subject? We argue that the race to elimination can be understood, simultaneously, as a product of posthuman forces, capable of being analysed using the theoretical tools made available via the posthuman turn; producing an intervention in what it means to be human; and generating a dilemma for people who use (or used) drugs, people with hepatitis C, and posthuman scholarship. In drawing out these issues, we aim to: trace the significant developments underway in hepatitis C medicine and raise awareness of them; encourage reflection on the consequences of these developments; and invite reflections on what might be lost when the human is remade by hepatitis C medicine.