Universal Testing in an ED Reveals Need for Widespread Implementation

Issue: August 2016

The epidemiology of hepatitis C indicates a substantial burden of disease lies within the so-called “Birth Cohort” population, which includes individuals born between 1945 and 1965. As a result, the CDC recommends that all people born between those years be tested at least once for HCV.

Although there is very strong rationale behind this recommendation, recent data from Galbraith and colleagues, suggest that our testing strategy could be — and perhaps should be — expanded to all individuals.

Galbraith started screening for HIV in the ED at University of Alabama at Birmingham Hospital several years ago. His group discovered a substantial proportion of individuals who had HIV but were unaware of their infection. Once they were identified in the ED, physicians referred them and linked them to care at the local HIV clinic. The success rates for linkage to care were about 80%.

A few years later, the same group began screening for HCV in the ED, expanding testing beyond the birth cohort to any individual unaware of his or her HCV status. This represented the majority of individuals presenting in the UAB ED.

As demonstrated in this issue of HCV Next, the results from the Galbraith experiment are quite striking. Nearly 12% of all individuals presenting to the ED were seropositive for HCV. Remarkably, those individuals who had some form of health insurance had a rate of 4% whereas those who were uninsured or underinsured had rates of 18%.

This is a striking value indicating that up to one in five individuals who live in poverty or have poor access to health care through lack of insurance coverage are the ones most affected by hepatitis C infection. They also are the ones who are most likely to not have access to care after diagnosis.

The Galbraith team went on to discover that while, as expected, there was a spike among those born in the traditional Birth Cohort, they saw a second spike of HCV-positive individuals for those aged 18 to 29 years. What differed was the younger group were mostly white, whereas the majority of those individuals testing positive in the Birth Cohort were black.

Taken together, the burden of hepatitis C in this urban ED was substantial and underscores the need for more universal screening. We need to test beyond those in the birth cohort and screen all individuals presenting for care in EDs, especially those who are uninsured or underinsured.

The Galbraith group referred and attempted to link these individuals to HCV clinics, although the success of this linkage was not quite as good as in the HIV experience. This may reflect the lack of sufficient treatment facilities in the local area or the lack of treatment facilities in more rural areas of the state.

We should learn from this experience and implement, where possible, more universal testing and screening in EDs as well as in primary care clinics. This is imperative if we want to have any chance of eradicating HCV in the United States by 2030.

- Michael S. Saag

Co-Chief Medical Editor

HCV Next