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Collaboration results in more hepatitis tests, fails to find chronic HCV cases
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Combining the efforts of public health and family practices were effective in more patients receiving hepatitis tests, but did not result in more chronic hepatitis C diagnoses, according to findings published in the Annals of Family Medicine.
“Both chronic hepatitis C and B virus infections are generally asymptomatic, and many remain undetected or are diagnosed at a late stage,” Jeanne Heil, MSc, from the Public Health Service in South Limburg, Heerlen, the Netherlands, and colleagues wrote. “Studies that evaluate best practice hepatitis testing strategies are needed to better detect this hidden population.”
Researchers stated that 11 family physicians in the Netherlands wrote a letter personally inviting their patients to take an HBV and HCV test at no charge at either the patient’s home, family practice location, public health service clinic or at the hospital. Public health services then sent out invitations and reminders to 6,743 participants aged 40 to 70 years to receive the tests in two hepatitis “hot spots” in the Netherlands. The public health services also arranged testing locations, planned tests and collected data.
Heil and colleagues found that 50.9% of patients took the tests, likely due to the family physician extending the invitation. In addition, positive test rates were 0.2% (95% CI, 0.08-0.42) for anti-HCV; 0.26% (95% CI, 0.12-0.5) for hepatitis B surface antigen; and 4.14% (95% CI, 3.49-4.86) for anti-hepatitis B core. However, there was no active or chronic HCV detected (95% CI, 0-0.11).
“[I]t is likely that the strategy taken would not be effective in other areas of the Netherlands and other low-prevalence countries. Our testing strategy can be applied to detecting HCV and HBV infections, as well as other infectious diseases, in high-endemic countries, such as the United States,” the researchers wrote. “If the test is not offered for free, however, a lack of health insurance could be a limiting factor in the United States. Considering the different health care system in the United States, the test uptake of a similar testing strategy might be lower in certain groups at risk, such as intravenous drug users or patients coinfected with HIV.” – by Janel Miller
Disclosures: The authors report no relevant financial disclosures.
Perspective
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Michael Saag, MD
This study in the Netherlands evaluated whether routine testing of people for HBV and HCV in family medicine clinics would be fruitful from a public health perspective. Remarkably, their screening efforts yielded very few undiagnosed cases of HCV or HBV. The authors concluded that in their country it did not make sense to adopt a widespread testing policy.
The initial response that some may have to this study is that testing for HBV and HCV in the primary care setting is a bad idea. But the authors quickly point out that HCV prevalence in the Netherlands is quite low, especially when compared to the U.S., and that each country and region has to decide what testing strategy is best for them.
Here in the U.S., HCV occurs in about 3% to 4% of the so-called baby boomers (those born between 1945 and 1965). Before such large-scale testing programs are initiated, some pilot data on the cost-effectiveness of such strategies should be collected and considered.
For the past 3 years here at the University of Alabama, we have been testing all patients who come into the ED and do not know their HCV status. Remarkably, we have found a 12% seropositive rate among these patients. This includes not just baby boomers, but also those aged 18 to 30 years, many of whom have been using opioids and injectable drugs. We have also found that those who have health insurance had about a 3% seropositivity rate, but those who were uninsured or underinsured had a serum positivity rate approaching 18%.
The take-home point from all of this is that we need to know who we’re evaluating and tailor public health and general practice approaches to testing based on our assessment of estimated seropositive rates. Based on seropositive rates in the United States, we should be routinely testing all patients for HCV and HBV, regardless of their age. Now that we have medications available that can cure HCV, we can begin to entertain the notion of eradication of HCV in the United States if we approach this in an informed, public health fashion.
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