Emergency department opt-out screening for viral hepatitis
and linkage to care is feasible and resulted in high uptake of testing,
researchers from a major London hospital report in the Journal of Viral
Hepatitis.
But the study also found that linkage to hepatitis C care
among previously undiagnosed people was challenging and required a high level of involvement
from social services and peer workers to locate people and ensure they remained
engaged in care.
Elimination of hepatitis B and hepatitis C depends on
screening people at higher risk of infection, diagnosis and linkage to
specialist care. But recent estimates suggest that two-thirds of hepatitis C
infections and 81% of hepatitis B infections remain undiagnosed in the United
Kingdom.
Risk-based screening for viral hepatitis in general practice
and drugs services each contribute to identifying previously undiagnosed infections.
Screening in emergency departments has been recommended by the European Centre
for Disease Prevention and Control, although evidence on its effectiveness and
feasibility has been lacking.
In England, several studies have shown a higher prevalence
of viral hepatitis among users of emergency department services than in the
general population. In areas of high HIV prevalence in England, universal
testing for HIV in emergency departments is already recommended but advice on
testing for viral hepatitis is lacking.
To investigate the effectiveness and sustainability of testing
for viral hepatitis in an emergency department, a cross-departmental research group
at Guy’s and St Thomas’ NHS Foundation Trust carried out a study of universal opt-out
testing for viral hepatitis and linkage to care in the emergency department at
St Thomas’ Hospital, which serves inner south London.
The electronic patient record system automatically ordered testing
for hepatitis B and C for every patient admitted if they needed other blood tests, with the option to opt out of
testing. Patients were provided with printed information about viral hepatitis
and its treatment in multiple languages and informed at the time of blood draw
of their right to opt out of testing for viral hepatitis.
Linkage to care was carried out by the care co-ordinator
rather than Emergency department physicians, removing a barrier to buy-in from Emergency
department physicians.
Hepatitis C testing was carried out as reflex testing, so
the same sample was tested for HCV antibody and HCV antigen. This procedure means
that people who test antibody positive do not have to be recalled for
confirmatory testing.
During the eleven-month service evaluation, 81,088 people
attended the emergency department and 36,865 received a blood test (45%). Of
these, 75% accepted hepatitis B testing and 75% accepted hepatitis C testing.
A total of 235 people (0.9%) had a positive test for
hepatitis B surface antigen, 523 (1.9%) had a positive hepatitis C antibody
test result and 261 (0.9%) had a positive hepatitis C antigen result. There was
no difference in testing uptake for either hepatitis B or C by age, gender or
ethnicity.
Hepatitis B positivity was more common in men (prevalence
ratio (PR) 1.5), in those aged 30-49 (PR 3.4) compared to other age groups and in
other ethnicities compared to White British (PR > 6.6).
Of those diagnosed with hepatitis B, 15% were already
engaged in care or had an end-of-life diagnosis unrelated to hepatitis B. Of
the remaining 199 patients, 140 (70%) received their hepatitis B diagnosis.
Just under half (48%) were already aware of their hepatitis B status and half
of these (53%) were not engaged in care.
A total of 110 patients required linkage to care; 87% were successfully
linked to care and of those linked to local services within the NHS Trust, 46
out of 86 (53%) had attended more than one clinic visit by the time of data
review.
In 261 people who tested positive for hepatitis C antigen,
prevalence was higher among men (PR 2.5), people who were homeless (PR 16.6) and
people who were HIV positive (PR 2.8). People aged 30-49 and 50-69 were significantly
more likely to test positive compared to younger people (PR 3.6). Prevalence
was significantly lower in other ethnic groups compared to White British
people.
Linkage to care for hepatitis C proved more challenging than
for hepatitis B. Approximately half (52%) of people who tested positive for
hepatitis C antigen could be contacted, although 12 died shortly after being
contacted and 19 were already engaged in care. Of the remaining 99, 56 accepted
linkage to care. Of those who attended appointments in the local NHS Trust, 26
of 34 had been successfully treated for hepatitis C by the time the data review was
completed.
Ninety-seven people diagnosed with hepatitis C were
homeless. Thirty-one of 87 homeless patients who could not be contacted by the
hospital were traced by the NHS Find and Treat team, of whom 19 were subsequently
approved for treatment or started treatment.
Barriers to linkage included the lack of an active mobile
phone number and lack of GP registration. The service evaluation found that
liaison with local homeless teams and peer support workers with experience of
homelessness was essential to locate and engage homeless people in care and
maintain their engagement in treatment.
The study authors say that emergency department opt-out testing
is more likely to be successful in urban settings with good co-ordination
between the Emergency department, clinical treatment and community teams, including
social services.