emergency department patients for hepatitis C virus (HCV) based on birth cohort
and risk profile might mean that a quarter of undiagnosed infections would
remain undetected, according to United States research published in the online
edition of Clinical Infectious Diseases.
the Johns Hopkins Hospital Emergency Department, Baltimore, tested all patients
attending the emergency room for HCV over an eight-week period in the summer of
2013. Approximately half of all infections detected were previously
undiagnosed, and a quarter of these undiagnosed infections would have been
missed had only screening protocols based on age and risk profile been applied.
suggest that urban EDs [emergency departments] should consider expanding CDC
[Centers for Disease Control] HCV testing recommendations to permit more robust
identification of those patients with unknown HCV,” comment the authors.
It has been
estimated that at least 2.2 to 3.2 million individuals in the United States are
living with HCV infection and that the majority of these patients are unaware
of their infection status. HCV prevalence is especially high in the 1945-65
birth cohort, often called the 'baby boomer' generation. Therefore in 2012 the
CDC issued guidance recommending one-off HCV testing for all patients in this
age group. The guidelines also recommend the screening of patients considered
to be at high risk of HCV infection, including individuals with a history of
injecting drug use (IDU), patients with HIV infection, and recipients of blood
departments are an ideal venue for the implementation of expanded HCV
screening. They serve diverse populations and are often used as a healthcare
safety net, therefore treating patients who do not access other medical
providers. Emergency departments have also successfully implemented routine HIV
Johns Hopkins University Hospital wanted to see how many undiagnosed HCV
infections would be picked up if all patients attending the emergency
department were screened for this infection. The investigators calculated the
proportion of infections detected after applying age- and risk-based screening
and also the proportion that would have been missed had screening been limited
to these criteria.
serves a diverse and socially disadvantaged population with high HCV and HIV
infection rates. The authors therefore believe it to be an ideal venue in which
to evaluate HCV screening recommendations.
All adult patients
attending the emergency department with excess blood collected for clinical
purposes were included in the study. Clinical data – including HCV infection
status and risk – were obtained from electronic patient records.
A total of 4,713
patients were included in the study and 652 (14%) were HCV antibody positive.
Approximately a third (31%) of the patients with HCV infection were previously
current age-based screening guidelines. HCV prevalence was higher among the 'baby boomer' patients than other birth cohorts (25% vs. 7%; p < 0.05) and
the 1945-65 birth cohort also had a higher prevalence of undiagnosed HCV
infections than other age groups (7% vs. 3%; p < 0.05).
of the undiagnosed patients showed that 49% would have been diagnosed using
age-based screening and that a further 26% would have been detected with risk-based
testing. However, the remaining 25% of undiagnosed patients would have left the
emergency department with their HCV infection undetected had screening not been
eight-week data, the investigators calculated that, over a twelve-month period,
7,727 patients with HCV infection would receive care in their emergency department
and that 2,419 of these individuals would be previously undiagnosed; 605 of
these infections would have remained undiagnosed using existing age- and
underscore the need for HCV management and treatment resources for HCV-infected
individuals who frequent the emergency department,” comment the authors.
recommend that all adult patients attending urban emergency departments should
be screened for HCV. But they are concerned that this will place strain on HCV
services. “Current workforce capacity for HCV care and treatment will unlikely
be able to meet the increased demands associated with identifying known and
previously undiagnosed HCV-infected individuals,” conclude the investigators.
“Therefore it is imperative to prioritize and integrate strategies for HCV
testing and long-term care while expanding the number of care providers with
expertise in HCV care and treatment.”