Prevalence of Hepatitis C Virus Infection Identified From Nontargeted Screening Among Adult Visitors in an Academic Appalachian Regional Emergency Department

Opioid Overdose Patients in Central Missouri, United States, Have High Rates of Hepatitis C Infection and Limited Testing History

BACKGROUND

Cases of newly identified hepatitis C virus (HCV) infection increased 3.8-fold between 2010 and 2017 due to increasing injection drug use. Furthermore, multiple HIV outbreaks have been attributed to injection drug use. This retrospective cohort study assessed the prevalence of and testing history for HIV and HCV among opioid overdose patients in the emergency department.

METHODS

Each encounter including an opioid overdose at three emergency departments between January 2021 and May 2022 was reviewed. Emergency department note, most recent primary care note, and laboratory results from January 2000 to May 2022 were reviewed for the history of HIV and HCV testing. Fisher's exact test was used to identify associations of HIV and HCV status with age or gender.

RESULTS

There were 134 encounters for 120 patients. A total of 72 were male and 48 were female. A total of 48 had a history of HCV testing. A total of 54 had a history of HIV testing. A total of 20 tested positive for HCV antibodies. One tested positive for HIV. Eight had detectable HCV viral loads, six had undetectable HCV viral loads, and six had no quantitative testing. One had a detectable HIV viral load. A total of 16.7% of both males and females had a history of a positive HCV test. Females were more likely to have ever received an HCV test compared to males (p=0.013, odds ratio (OR)=.68 (confidence interval (CI): 1.293-5.836)). Patients aged 55-64 were more likely to test positive than any other age group (p=0.018, OR=3.889 (CI: 1.391-11.81)), and were the least likely to be untested (p=0.037, OR=0.1905 (CI: 0.03914-0.9334)).

CONCLUSION

There is a substantial burden of HCV among opioid overdose patients in central Missouri, United States, emergency departments, particularly among male patients and those aged 55-64. Universal HCV screening for individuals being observed following an overdose could detect many undiagnosed HCV infections.

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.

Non-targeted hepatitis C virus screening in acute care healthcare settings in the Southern Appalachian region

Objectives

The objective of this study was to evaluate the performance of non-targeted hepatitis C virus (HCV) screening in emergency departments (EDs) and other healthcare settings in terms of patients identified with HCV infection and linked to HCV care.

Methods

In the Southern Appalachian region of the United States, we developed non-targeted HCV screening and linkage-to-care programs in 10 institutions at different healthcare settings, including EDs, outpatient clinics, and inpatient units. Serum samples were tested for HCV antibodies, and if positive, reflexed to HCV ribonucleic acid (RNA) testing as a confirmatory test for active infection. Patients with positive RNA tests were contacted to link them to HCV care.

Results

Between 2017 and 2019, among 195,152 patients screened for HCV infection, 16,529 (8.5%) were positive by antibody testing, 10,139 (5.2% of screened patients and 61.3% of patients positive by antibody test) were positive by RNA testing, and 5778 (3.0% of screened patients and 57.0% of patients positive by RNA test) were successfully linked to HCV care. Among 83,645 patients screened in EDs, 9060 (10.8%) were positive by HCV antibody, and 5243 (6.3%) were positive by RNA test. Among patients positive by RNA testing, linkage to care was lower for patients screened in the ED (44.1%) compared with outpatient clinics (67.6%) (P < 0.01) and inpatient units (50.9%) (P < 0.01).

Conclusions

Non-targeted HCV screening in acute care settings can identify large numbers of people with HCV infection. To optimize the utility of these screening programs, future work is needed to develop best practices that consistently link these patients to HCV care.

Liver function tests in primary care provide a key opportunity to diagnose and engage patients with hepatitis C

Since the advent of direct-acting antiviral therapy, the elimination of hepatitis c virus (HCV) as a public health concern is now possible. However, identification of those who remain undiagnosed, and re-engagement of those who are diagnosed but remain untreated, will be essential to achieve this. We examined the extent of HCV infection among individuals undergoing liver function tests (LFT) in primary care. Residual biochemistry samples for 6007 patients, who had venous blood collected in primary care for LFT between July 2016 and January 2017, were tested for HCV antibody. Through data linkage to national and sentinel HCV surveillance databases, we also examined the extent of diagnosed infection, attendance at specialist service and HCV treatment for those found to be HCV positive. Overall HCV antibody prevalence was 4.0% and highest for males (5.0%), those aged 37–50 years (6.2%), and with an ALT result of 70 or greater (7.1%). Of those testing positive, 68.9% had been diagnosed with HCV in the past, 84.9% before the study period. Most (92.5%) of those diagnosed with chronic infection had attended specialist liver services and while 67.7% had ever been treated only 38% had successfully cleared infection. More than half of HCV-positive people required assessment, and potentially treatment, for their HCV infection but were not engaged with services during the study period. LFT in primary care are a key opportunity to diagnose, re-diagnose and re-engage patients with HCV infection and highlight the importance of GPs in efforts to eliminate HCV as a public health concern.

Prevalence of hepatitis C in sexual assault survivors presenting to a SANE clinic: A descriptive analysis

While previous epidemiologic research has demonstrated that sexual assault survivors (SAS) may be at disproportionate risk for exposure to Hepatitis C (HCV), HCV screening in SAS is not addressed in current post-sexual assault testing recommendations. We sought to identify the prevalence of HCV among a SAS cohort along with associated basic demographics. Opt-out HCV antibody screening and RNA confirmatory testing was provided for all SAS at a Sexual Assault Nurse Examiner (SANE) clinic in Birmingham, Alabama, from April 2020 through March 2021. A retrospective chart review was conducted using descriptive statistical and Chi-squared analyses. A total of 293 SAS presented to the clinic during the study timeframe. Two hundred forty-two (82.6%) were screened for HCV and 26 (8.9%) were found to be HCV antibody (Ab) positive [significantly higher than state (<1.0%) and national (1.0%) HCV incidence rates (p < 0.0001)]. SAS age groups 25-34 and 35-44 were more likely to screen HCV Ab-positive (15.2% and 14.9% respectively; p = 0.02). Female SAS were more likely to be tested for HCV then males (p = 0.02), although male SAS were more likely to be found HCV Ab-positive when screened (24.4%, p < 0.0001). Overall, SAS demographics also demonstrate the presence of significant social vulnerabilities, specifically high rates of homelessness (4.4%) and incarceration (5.1%). This data highlight the potential impact of universal HCV screening and risk counselling in a high social risk population and suggests a potential for future focused interventions.