An innovative approach to increase viral hepatitis diagnoses and linkage to care using opt-out testing and an integrated care pathway in a London Emergency Department

Anti-Hepatitis C (HCV) test positivity and new HCV diagnoses among women tested in antenatal services in England between 2015-2019

OBJECTIVE

To determine associations with hepatitis C virus (HCV) positivity, new HCV diagnoses and subsequent linkage to HCV treatment services among pregnant women in England.

METHOD

A retrospective cohort using routine laboratory tests for HCV-specific antibody (anti-HCV) and HCV-RNA undertaken during antenatal attendances England. All women receiving at least one anti-HCV test during an antenatal clinic attendance between 2015 and 2019 were included. Multivariable logistic regression was used to investigate sociodemographic associations with anti-HCV test positivity among pregnant women who did (PWIDs) and did not (non-PWIDs) inject drugs, as well as to identify sociodemographic factors associated with being newly diagnosed during pregnancy. Linkage to antiviral treatment services and treatment outcomes were determined for those women who tested HCV-RNA positive.

RESULTS

32,088 women (median age 32 years, 19,664 (61 %) UK-born, 337 (1.1 %) PWID) received an anti-HCV test among whom 814 (2.5 %) had a positive anti-HCV test (95 % confidence interval [2.4-2.7 %]). Anti-HCV test positivity was 2.1 % [2.0-2.3 %] among non-PWIDs and 40 % [35-46 %] among PWIDs. In multivariable analyses among non-PWIDs, anti-HCV test positivity was associated with older age, living in more deprived areas, and varied by ethnicity and country of birth. Among PWIDs, anti-HCV test positivity was associated with older age only. Three hundred and twenty (39 %) of the women testing anti-HCV positive were new diagnoses; those who were newly diagnosed were younger and lived in less deprived than those with a prior diagnosis whereas PWIDs were less likely to be newly diagnosed. HCV-RNA positivity was 52 % (n = 330/640, 95 %CI[47.6-55.5 %]) among those with an HCV-RNA test within 30 days, and 75 % (n = 220/293, 95 %CI[69.7-79.9 %]) of those eligible for treatment had engaged in HCV treatment services after antenatal testing.

CONCLUSIONS

Antenatal testing for HCV provides an opportunity for new case findings and engagement with treatment services where needed. Therefore, universal opt-out testing for HCV antenatally should be reconsidered.

Prevalence, characteristics and challenges of late HIV diagnosis in Germany: an expert narrative review

PURPOSE

We aimed to review the landscape of late HIV diagnosis in Germany and discuss persisting and emerging barriers to earlier diagnosis alongside potential solutions.

METHODS

We searched PubMed for studies informing the prevalence, trends, and factors associated with late HIV diagnosis in Germany. Author opinions were considered alongside relevant data.

RESULTS

In Germany, older individuals, heterosexuals, and migrants living with HIV are more likely to be diagnosed late. The rate of late diagnosis in men who have sex with men (MSM), however, continues to decrease. Indicator conditions less often prompt HIV testing in women and non-MSM. During the COVID-19 pandemic, the absolute number of late diagnoses fell in Germany, but the overall proportion increased, probably reflecting lower HIV testing rates. The Ukraine war and subsequent influx of Ukrainians living with HIV may have substantially increased undiagnosed HIV cases in Germany. Improved indicator testing (based on unbiased assessments of patient risk) and universal testing could help reduce late diagnoses. In patients who receive a late HIV diagnosis, rapid treatment initiation with robust ART regimens, and management and prevention of opportunistic infections, are recommended owing to severely compromised immunity and increased risks of morbidity and mortality.

CONCLUSION

Joint efforts are needed to ensure that UNAIDS 95-95-95 2030 goals are met in Germany. These include greater political will, increased funding of education and testing campaigns (from government institutions and the pharmaceutical industry), continued education about HIV testing by HIV experts, and broad testing support for physicians not routinely involved in HIV care.

Blood-borne virus testing in emergency departments - a systematic review of seroprevalence, feasibility, acceptability and linkage to care

BACKGROUND

Blood-borne viruses (BBVs) cause significant morbidity and mortality worldwide. Emergency departments (EDs) offer a point of contact for groups at increased risk of BBVs who may be less likely to engage with primary care. We reviewed the literature to evaluate whether BBV testing in this setting might be a viable option to increase case finding and linkage to care.

METHODS

We searched PubMed database for English language articles published until June 2019 on BBV testing in EDs. Studies reporting seroprevalence surveys, feasibility, linkage to care, enablers and barriers to testing were included. Additional searches for grey literature were performed.

RESULTS

Eight-nine articles met inclusion criteria, of which 14 reported BBV seroprevalence surveys in EDs, 54 investigated feasibility and acceptability, and 36 investigated linkage to care. Most studies were HIV-focused and conducted in the USA. Seroprevalence rates were in the range 1.5-17% for HCV, 0.7-1.6% for HBV, and 0.8-13% for HIV. For studies that used an opt-in study design, testing uptake ranged from 2% to 98% and for opt-out it ranged from 16% to 91%. There was a wide range of yield: 13-100% of patients received their test result, 21-100% were linked to care, and 50-91% were retained in care. Compared with individuals diagnosed with HIV, linkage to and retention in care were lower for those diagnosed with hepatitis C. Predictors of linkage to care was associated with certain patient characteristics.

CONCLUSIONS

Universal opt-out BBV testing in EDs may be feasible and acceptable, but linkage to care needs to be improved by optimizing implementation. Further economic evaluations of hepatitis testing in EDs are needed.

Hospital-based preventative interventions for people experiencing homelessness in high-income countries: A systematic review

BACKGROUND

People experiencing homelessness have significant unmet needs and high rates of unplanned care. We aimed to describe preventative interventions, defined in their broadest sense, for people experiencing homelessness in a hospital context. Secondary aims included mapping outcomes and assessing intervention effectiveness.

METHODS

We searched online databases (MEDLINE, Embase, PsycINFO, HMIC, CINAHL, Web of Science, Cochrane Library) from 1999-2019 and conducted backward and forward citation searches to 31 December 2020 (PROSPERO CRD42019154036). We included quantitative studies in emergency and inpatient settings measuring health or social outcomes for adults experiencing homelessness in high income countries. We assessed rigour using the "Quality Assessment Tool for Quantitative Studies" and summarised findings using descriptive quantitative methods, a binomial test, a Harvest Plot, and narrative synthesis. We used PRISMA and SWiM reporting guidelines.

FINDINGS

Twenty-eight studies identified eight intervention types: care coordination (n=18); advocacy, support, and outreach (n=13); social welfare assistance (n=13); discharge planning (n=12); homelessness identification (n=6); psychological therapy and treatment (n=6); infectious disease prevention (n=5); and screening, treatment, and referrals (n=5). The evidence strength was weak (n=16) to moderate (n=10), with two high quality randomised controlled trials. We identified six outcome categories with potential benefits observed for psychosocial outcomes, including housing (11/13 studies, 95%CI=54.6-98.1%, p=0.023), healthcare use (14/17, 56.6-96.2%, p=0.013), and healthcare costs (8/8, 63.1-100%, p=0.008). Benefits were less likely for health outcomes (4/5, 28.3-99.5%, p=0.375), integration with onward care (2/4, 6.8-93.2%, p=1.000), and feasibility/acceptability (5/6, 35.9-99.6%, p=0.219), but confidence intervals were very wide. We observed no harms. Most studies showing potential benefits were multi-component interventions.

INTERPRETATION

Hospital-based preventative interventions for people experiencing homelessness are potentially beneficial, but more rigorous research is needed. In the context of high needs and extreme inequities, policymakers and healthcare providers may consider implementing multi-component preventative interventions.

FUNDING

SL is supported by an NIHR Clinical Doctoral Research Fellowship (ICA-CDRF-2016-02-042). JD is supported by an NIHR School of Public Health Research Pre-doctoral Fellowship (NU-004252). RWA is supported by a Wellcome Clinical Research Career Development Fellowship (206602).

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.

Real-world clinical effectiveness and sustainability of universal bloodborne virus testing in an urban emergency department in the UK

Innovative testing approaches and care pathways are required to meet HIV, hepatitis B (HBV) and hepatitis C (HCV) elimination goals. Routine testing for blood-borne viruses (BBVs) within emergency departments (EDs) is suggested by the European Centre for Disease Prevention and Control but there is a paucity of supporting evidence. We evaluated the introduction of routine BBV testing in EDs at a large teaching hospital in northern England. In October 2018, we modified the electronic laboratory ordering system to reflex opt-out HIV, HBV and HCV testing for all ED attendees aged 16-65 years who had a routine blood test for urea and electrolytes (U&Es). Linkage to care (LTC) was attempted for newly diagnosed patients, those never referred and those who had previously disengaged from care. The project operated for 18 months, here we present evaluation of the initial nine months (2 October 2018-1 July 2019). We analysed testing uptake, BBV seropositivity, LTC and treatment initiation within six months post-diagnosis. Over 9 months, 17,026/28,178 (60.4%) ED attendees who had U&Es performed were tested for ≥ 1 BBV. 299 active BBV infections were identified: 70 HIV Ab/Ag-positive (0.4% seroprevalence), 73 HBsAg-positive (0.4%) and 156 HCV RNA-positive (1.0%). Only 24.3% (17/70) HIV Ab/Ag-positive individuals required LTC, compared to 94.9% (148/156) HCV RNA-positive and 53.4% (39/73) HBsAg-positive individuals. LTC was successful in 94.1% (16/17) HIV Ab/Ag-positive and 69.3% (27/39) HBsAg-positive individuals. However, at 6 months LTC was just 39.2% (58/148) for HCV RNA-positive individuals, with 64% (37/58) of these commencing treatment. Universal opt-out ED BBV testing proved feasible and effective in identifying active BBV infections, especially among marginalised populations with reduced healthcare access. Our integrated approach achieved good LTC rates although further service development is necessary, particularly for HCV RNA-positive people who inject drugs.

VirA+EmiC project: Evaluating real-world effectiveness and sustainability of integrated routine opportunistic hepatitis B and C testing in a large urban emergency department

Innovative testing approaches and care pathways are required to meet global hepatitis B virus (HBV) and hepatitis C virus (HCV) elimination goals. Routine blood-borne virus (BBV) testing in emergency departments (EDs) in high-prevalence areas is suggested by the European Centre for Disease Prevention and Control (ECDC) but there is limited evidence for this. Universal HIV testing in our ED according to UK guidance has been operational since 2015. We conducted a real-world service evaluation of a modified electronic patient record (EPR) system to include opportunistic opt-out HBV/reflex-HCV tests for any routine blood test orders for ED attendees aged ≥16 years. Reactive laboratory results were communicated directly to specialist clinical teams. Our model for contacting patients requiring linkage to care (new diagnoses/known but disengaged) evolved from initially primarily hospital-led to collaborating with regional health and community service networks. Over 11 months, 81,088 patients attended the ED; 36,865 (45.5%) had a blood test. Overall uptake for both HBV and HCV testing was 75%. Seroprevalence was 0.9% for hepatitis B surface antigen (HBsAg) and 0.9% for HCV antigen (HCV-Ag). 79% of 140 successfully contacted HBsAg+patients required linkage to care, of which 87% engaged. 76% of 130 contactable HCV-Ag+patients required linkage, 52% engaged. Our results demonstrate effectiveness and sustainability of universal ED EPR opt-out HBV/HCV testing combined with comprehensive linkage to care pathways, allowing care provision particularly for marginalized at-risk groups with limited healthcare access. The findings support the ECDC BBV testing guidance and may inform future UK hepatitis testing guidance.

Elimination of Hepatitis C in Southern Italy: A Model of HCV Screening and Linkage to Care among Hospitalized Patients at Different Hospital Divisions

Background: Free-of-charge HCV screening in some key populations and in 1969–1989 birth cohorts has been funded in Italy as the first step to diagnosing individuals who are infected but asymptomatic. The aim of this study is to evaluate the feasibility of an opportunistic HCV screening and its linkage to care. Methods: A hospital-based HCV screening was conducted as a routine test for in-patients admitted to the Evangelical Hospital Betania of Naples from January 2020 to May 2021. All consecutive in-patients were screened for the HCV antibody (HCV-Ab) at the time of their admission to the hospital, and those born prior to year 2000 were included in the study. HCV-RNA testing was required for those not previously treated and without antiviral treatment contraindications. For in-patients with an active infection, treatment started soon after hospital admission. Results: Among 12,665 inpatients consecutively screened, 510 (4%) were HCV-Ab positive. The HCV-Ab positivity rate increased with age, reaching the highest prevalence (9.49%) in those born before 1947. Among patients positive for HCV, 118 (23.1%) had been previously treated, 172 (33.9%) had been discharged before being tested for HCV-RNA, and 26 (5.1%) had not been tested for short life expectancy. Of 194 (38% of HCV-Ab+) patients who were tested for HCV-RNA, 91 (46.2%) were HCV-RNA positive. Of patients with active infection, 33 (36%) were admitted to the liver unit with signs of liver damage either not previously diagnosed or diagnosed but unlinked to care for HCV infection. Of the patients positive for HCV-RNA, 87 (95.6%) started treatment; all achieved sustained virological response. Conclusion: HCV active infection has been frequently found in patients with comorbidities admitted in the hospital in Southern Italy. To achieve HCV elimination in Italy, broader screening strategies are required. In addition to screening of the 1969–1989 birth cohort of individuals unaware of their infection status, diagnosis and linkage to care of patients with known liver damage is strictly required. Hospital screening is feasible, but prompt reflex testing for identifying HCV-active infections is necessary to increase diagnosis and subsequent linkage to care.

Screening for Chronic Infectious Diseases by Serology in Those Presenting with Malaria in London, United Kingdom

The United Kingdom's cases of malaria infection are primarily acquired in sub-Saharan Africa, with the majority of infections presenting in London.1 When patients go to a hospital with malaria, there is a screening opportunity for other geographically associated chronic infections. We identified patients who were diagnosed with malaria after presenting to our emergency department in London over a 2-year period, to assess whether there may be clinical benefit in screening for chronic viral (hepatitis B, hepatitis C, HIV) or parasitic (schistosomiasis, strongyloidiasis) infection in this cohort. Over this period, 131 patients were diagnosed with malaria. Crude seropositivity rates for HIV, hepatitis B, and strongyloidiasis were higher than expected compared with local population estimates, 7 and 28 times higher for HIV and hepatitis B, respectively. Those patients with previously unidentified cases were offered appropriate treatment. These findings support the potential clinical and public health benefits of screening for other infectious diseases in the context of a malaria diagnosis.

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.

Optimizing diagnostic algorithms to advance Hepatitis C elimination in Italy: A cost effectiveness evaluation

OBJECTIVES

Optimized diagnostic algorithms to detect active infections are crucial to achieving HCV elimination. We evaluated the cost effectiveness and sustainability of different algorithms for HCV active infection diagnosis, in a context of a high endemic country for HCV infection.

METHODS

A Markov disease progression model, simulating six diagnostic algorithms in the birth cohort 1969-1989 over a 10-year horizon from a healthcare perspective was used. Conventionally diagnosis of active HCV infection is through detection of antibodies (HCV-Ab) detection followed by HCV-RNA or HCV core antigen (HCV-Ag) confirmatory testing either on a second sample or by same sample reflex testing. The undiagnosed and unconfirmed rates were evaluated by assays false negative estimates and each algorithm patients' drop-off. Age, liver disease stages distribution, liver disease stage costs, treatment effectiveness and costs were used to evaluate the quality-adjusted life-years (QALYs) and the incremental cost-effectiveness ratios (ICER).

RESULTS

The reference option was Rapid HCV-Ab followed by second sample HCV-Ag testing which produced the lowest QALYs (866,835 QALYs). The highest gains in health (QALYs=974,458) was obtained by HCV-RNA reflex testing which produced a high cost-effective ICER (€891/QALY). Reflex testing (same sample-single visit) vs two patients' visits algorithms, yielded the highest QALYs and high cost-effective ICERs (€566 and €635/QALY for HCV-Ag and HCV-RNA, respectively), confirmed in 99.9% of the 5,000 probabilistic simulations.

CONCLUSIONS

Our data confirm, by a cost effectiveness point of view, the EASL and WHO clinical practice guidelines recommending HCV reflex testing as most cost effective diagnostic option vs other diagnostic pathways.

HCV core antigen plays an important role in the fight against HCV as an alternative to HCV-RNA detection

Objective

To discuss the clinical significance of HCV‐cAg testing in the diagnosis, activity determination, and monitoring of therapeutic effectiveness of HCV infection and its advantages compared with HCV‐RNA and anti‐HCV antibodies detection.

Methods

By summarizing the published literature, the advantages and significance of HCV core antigen detection were sought.

Results

The expression of HCV‐cAg is highly consistent with that of HCV‐RNA, but compared with HCV‐RNA, detection of HCV‐cAg is easy to operate, time saving, and low cost. HCV‐cAg can be detected within 12~15 days after infection, and the window period can be shortened by5~7 weeks. HCV‐cAg is a serological indicator of virus replication, which can distinguish previous infection of HCV or current infection. HCV‐cAg detection is more suitable for immunocompromised, hemodialysis, organ transplant patients. HCV‐cAg also can be used to monitor antiviral efficacy and predict sustained virological response (SVR).

Conclusion

HCV core antigen has similar clinical sensitivity to NAT and can be used as a substitute for HCV‐RNA in the diagnosis of virus infection. Combined detection of HCV‐cAg and antibody serology can help doctors detect HCV infection earlier, accurately diagnose different stages of HCV infection, and evaluate the therapeutic effect of antiviral drugs, which are beneficial in the prevention and treatment of hepatitis C.

Laboratory Medicine and Healthcare Excellence - Till Death do us Part

The union between laboratory medicine and healthcare excellence is strong, interconnected and has stood the test of time. This partnership is essential in the quest for value-based health care, expanding the strategic role of the clinical laboratory from traditional, transactional models to strategic ones that expedite or activate new cascades of care. This paper reviews outcomes and key trends following global recognition of integrated clinical care teams for exemplary outcomes of measurably better health care. In all cases, laboratory medicine was either a key contributor or leader in predictive risk management, preventative health, and integration of clinical care through active synthesis of relevant data: data that are too often under-used, under-recognized, or even missing in traditional models of care. Outcomes connect multi-disciplinary teams with favorable key performance indicators across patients, payors, clinicians and health systems, as well as top disease burdens and unmet gaps of care. Results affirm the possibilities ahead with proactive engagement across healthcare professionals including the vital and active role of laboratory medicine. With the future upon us, it is incumbent upon all healthcare professionals to work together, learn from others, champion health outcomes and join in a pledge for healthcare excellence.

Toward microelimination of hepatitis C and HIV coinfection in NHS Tayside, Scotland: Real-world outcomes

BACKGROUND AND AIMS

NHS Tayside is a health board in Scotland which serves around 400 000 residents. Approximately, 2761 are estimated to be persons who inject drugs (PWID), and therefore at risk of infections such as hepatitis C (HCV) and HIV. There are few studies exploring mechanisms and success of eliminating HCV in HIV co-infected PWID using real-world data. This study aims to empirically assess HCV treatment outcomes in people living with HIV (PLHIV) to evaluate progress toward microelimination of HCV in the HIV-positive population in Tayside.

METHODS

HCV testing and treatment details for PLHIV stored on clinical databases dating from 2001 were extracted and anonymized. HCV treatment uptake among co-infected patients eligible for HCV treatment was calculated. Reinfection incidence was calculated in person years. Confidence intervals were calculated assuming Poisson distribution. Caldicott Guardian approval was obtained to access patient data (ref: IGTCAL 5677).

RESULTS

Ninety-six percent of PLHIV were tested for HCV across nine services and aware of their HCV status. From 2001 to 2019, 58 PLHIV were HCV co-infected. Four left the area and five died prior to HCV treatment. Forty-nine were eligible for HCV treatment. Thirty were treated with PEGylated interferon (Peg-IFN); 18 with direct acting antivirals (DAA). One is yet to be treated. Twelve treated with Peg-IFN did not achieve sustained viral response (SVR12); 10 were retreated, two died prior to re-treatment. Injecting drug use was the mode of HCV transmission for 39 of 49 patients. Proportion who achieved SVR12 is 75%; 92% if treated with DAAs. Annual proportions of PLHIV treated for HCV increased from 3.57% in the Peg-IFN era to 66.67% in the DAA era. Reinfection incidence is 0.2 per 100 person years (CI -0.3 to 0.7).

CONCLUSIONS

NHS Tayside has made progress toward microelimination of HCV among PLHIV. The most common mode of HCV transmission in PLHIV in NHS Tayside is injecting drug use. DAAs increased the proportion of co-infected PLHIV treated for HCV and produced superior SVR12 results compared to Peg-IFN.

Opt-out Consent in Children's Emergency Medicine Research

There is global acceptance that individuals should be allowed to decide whether or not to take part in research studies, and to do so after being informed about the nature of the research and the risk that might attach to participation. The process of providing detailed information before seeking consent (formalized by signatures) in advance of undertaking research procedures may not be possible in some circumstances, and sometimes an amended approach may be adopted. The use of opt-out consent has been recognized as a valid and ethical means of recruiting participants to studies particularly with large samples and where the risk to participants is small. However, it is sometimes misunderstood and can be a problematic factor in being accepted by research ethics committees and governing authorities. This may be due partly to differing expectations of the amount of information and support offered, together with the nature of the process that is adopted to ensure that a decision has been made rather than consent simply being assumed. In accordance with ongoing discussions with young people, and following consultation with parents, an opt-out consent strategy including varied means of providing information was employed in a large study of 44,501 cases of children attending emergency or urgent care departments. The study was conducted over more than 12 months in dissimilar emergency departments and an urgent care unit, and was designed to support better decision-making in pediatric emergency departments about whether children need to be admitted to hospital or can be discharged home safely. Robust analysis of the factors that exerted the greatest impact on predicting the need to admit or the safety of discharging children led to a revised version of an existing tool. In this article, we review approaches to consent in research, the nature and impact of opt-out consent, the factors that made this an effective strategy for this study, but also more recent concerns which may make opt-out consent no longer acceptable.

An Economic Evaluation of the Cost-Effectiveness of Opt-Out Hepatitis B and Hepatitis C Testing in an Emergency Department Setting in the United Kingdom

OBJECTIVES

The prevalence of hepatitis is high in emergency department (ED) attendees in the United Kingdom, with a prevalence of up to 2% for hepatitis B (HBV) HBsAg, and 2.9% for hepatitis C (HCV) RNA. The aim of this paper is to perform an economic evaluation of opt-out ED-based HCV and HBV testing.

METHODS

A Markov model was developed to analyze the cost-effectiveness of opt-out HCV and HBV testing in EDs in the UK. The model used data from UK studies of ED testing to parameterize the HCV and HBV prevalence (1.4% HCV RNA, 0.84% HBsAg), test costs, and intervention effects (contact rates and linkage to care). For HCV, we used an antibody test cost of £3.64 and RNA test cost of £68.38, and assumed direct-acting antiviral treatment costs of £10 000. For HBV, we used a combined HBsAg and confirmatory test cost of £5.79. We also modeled the minimum prevalence of HCV (RNA-positive) and HBV (HBsAg) required to make ED testing cost-effective at a £20 000 willingness to pay per quality-adjusted life-year threshold.

RESULTS

In the base case, ED testing was highly cost-effective, with HCV and HBV testing costing £8019 and £9858 per quality-adjusted life-year gained, respectively. HCV and HBV ED testing remained cost-effective at 0.25% HCV RNA or HBsAg prevalence or higher.

CONCLUSIONS

Emergency department testing for HCV and HBV is highly likely to be cost-effective in many areas across the UK depending on their prevalence. Ongoing studies will help evaluate ED testing across different regions to inform testing guidelines.

The emergency department as a setting-specific opportunity for population-based hepatitis C screening: An economic evaluation

BACKGROUND AND AIMS

The World Health Organization's hepatitis C virus (HCV) elimination strategy recognizes the need for interventions that identify populations most affected by infection. The emergency department (ED) has been suggested as a setting for HCV screening. The study objective was to explore the health and economic impact of HCV screening in the ED setting.

METHODS

We used a microsimulation model to conduct a cost-utility analysis evaluating two ED setting-specific strategies: no screening, and screening and subsequent treatment. Strategies were examined for two populations: (a) the general ED patient population; and (b) ED patients born between 1945 and 1975. The analysis was conducted from a healthcare payer perspective over a lifetime time horizon. A reference and high ED HCV seroprevalence measure were examined in the Canadian healthcare setting.US costs of chronic infection were used for a scenario analysis of screening in the US healthcare setting.

RESULTS

For birth cohort screening, in comparison to no screening, one liver-related death was averted for every 760 and 123 persons screened for the reference and high seroprevalence measures. For general population screening, one liver-related death was averted for every 831 and 147 persons screened for the reference and high seroprevalence measures. In comparison to no screening, birth cohort screening was cost-effective at CAN$25,584/quality-adjusted life year (QALY) and US$42,615/QALY. General population screening was cost-effective at CAN$19,733/QALY and US$32,187/QALY.

CONCLUSIONS

ED screening may represent a cost-effective component of population-based strategies to eliminate HCV. Further studies are warranted to explore the feasibility and acceptability of this approach.

Hepatitis B screening in an argentine ED: Increasing vaccination in a resource-limited setting

BACKGROUND

There is limited data regarding the use of emergency departments (EDs) for infectious disease screening and vaccination in resource-limited regions. In these settings, EDs are often the only contact that patients have with the healthcare system, turning an ED visit into an opportune time to deliver preventative health services.

METHODS

In this pilot study, patients that met inclusion criteria were prospectively tested for hepatitis B surface antigen test (HBsAg). Previously unvaccinated patients who tested negative for HBsAg were offered HBV vaccination. The study setting was a public infectious disease hospital in Cordoba, Argentina. The primary outcomes were new HBV diagnoses, as well as vaccination completion between screening modalities (Point-of-Care-Testing-POCT vs. laboratory testing) and same vs. different day vaccination.

RESULTS

We screened 100 patients for HBV (75 POCT & 25 laboratory). The median age of participants was 35 years (IQR 24-52) and 55% were male. No patients tested positive for HBsAg. All patients who completed first dose vaccination were initially screened with the POCT. No patients screened with laboratory testing returned for vaccination. Patients who were scheduled for vaccination the same day were more likely to complete vaccination compared to those scheduled for another day (75% vs. 14%, p < .001).

CONCLUSION

Our study supports the use of HBV POCTs in the ED in conjunction with vaccination of HBV-negative individuals. In regions with low HBV endemicity, direct vaccination without HBsAg testing may be more cost effective. We believe that this acute-care screening model is applicable to other resource-limited settings.

The testing of people with any risk factor for hepatitis C in community pharmacies is cost-effective

New antiviral drugs with high efficacy mean the hepatitis C virus (HCV) can now be eliminated. To achieve this, it is necessary to identify undiagnosed cases of HCV. However, the costs of testing should be considered when judging the overall cost-effectiveness of treatment. This study describes the cost-effectiveness of a community pharmacy testing service in a population of people at risk of HCV living on the Isle of Wight (United Kingdom). Dry blood spot testing was conducted in anyone with a known risk factor for HCV in 20 community pharmacies. The outcomes and costs were entered into a Markov model. Cost and health utilities from the model were used to calculate an incremental cost-effectiveness ratio (ICER). In 24 months, 186 tests were conducted, 13 were positive for HCV RNA and six of these (46%) received treatment during the follow-up period. All achieved a sustained virological response at 3 months. The overall cost of the testing and treatment intervention was £242 183, and the ICER for the service was £3689 per quality-adjusted life year (QALY) gained. If screening had been restricted to just people with a history of injecting drug use (PWID) the ICER would have been £4865 per QALY gained. The service was effective at identifying people with HCV infection, and despite the additional cost of targeted testing, its cost-effectiveness was below the commonly accepted thresholds. In this setting, restricting targeted testing to PWID would not improve the cost-effectiveness.

Seroprevalence and demographic factors associated with hepatitis B, hepatitis C and HIV infection from a hospital emergency department testing programme, London, United Kingdom, 2015 to 2016

BackgroundProgress towards HIV, hepatitis B virus (HBV) and hepatitis C virus (HCV) elimination requires local prevalence estimates and linkage to care (LTC) of undiagnosed or disengaged cases.AimWe aimed to estimate seroprevalence, factors associated with positive blood-borne virus (BBV) serology and numbers needed to screen (NNS) to detect a new BBV diagnosis and achieve full LTC from emergency department (ED) BBV testing.MethodsDuring a 9-month programme in an ED in east London, England, testing was offered to adult attendees having a full blood count (FBC). We estimated factors associated with positive BBV serology using logistic regression and NNS as the inverse of seroprevalence. Estimates were weighted to the age, sex and ethnicity of the FBC population.ResultsOf 6,211 FBC patients tested, 217 (3.5%) were positive for at least one BBV. Weighted BBV seroprevalence was 4.2% (95% confidence interval (CI): 3.6-4.9). Adjusted odds ratios (aOR) of positive BBV serology were elevated among patients that were: male (aOR: 2.7; 95% CI: 1.9-3.9), 40-59 years old (aOR: 1.9; 95% CI: 1.4-2.7), of Black British/Black other ethnicity (aOR: 1.8; 95% CI: 1.2-2.8) or had no fixed address (aOR: 2.9; 95% CI: 1.5-5.5). NNS to detect a new BBV diagnosis was 154 (95% CI: 103-233) and 135 (95% CI: 93-200) to achieve LTC.ConclusionsThe low NNS suggests routine BBV screening in EDs may be worthwhile. Those considering similar programmes should use our findings to inform their assessments of anticipated public health benefits.