Emergency departments (ED) can be effective places to screen for undiagnosed hepatitis C and possibly other illnesses, resulting in treatment and reduced transmission of illnesses, according to a study published in Clinical Infectious Diseases.

Michael S Lyons, MD, Associate Professor of the Department of Emergency Medicine and Director of the Early Intervention program at the at the University Cincinnati, Ohio’s College of Medicine and colleagues examined a single, urban Midwestern ED at a teaching hospital that had 450 beds and treated 90,000 patients yearly. Of these, researchers reported 50% of patients were black and 40% were uninsured.

Patients between the ages of 18-64 were enrolled in a cross-sectional seroprevalence study and gave anonymous blood samples and health histories for compensation. An antibody assay was performed using the Biochain ELISA kit, and Qiagen QIAamp UltraSens Virus kit detected viral RNA. Next, researchers used real-time reverse transcription polymerase chain reaction.


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Of 924 samples, HCV antibody was detected in 128, or 14% of patients, 44 of whom already knew they had hepatitis C (HCV) or another type of hepatitis. 103 of the 128 positive HCV antibody samples also tested positive for viral RNA. Two patients tested RNA positive but antibody negative.

This screening caught more HCV cases than would normally be seen in the usual HCV target cohort group. “Fully implemented birth cohort screening [which usually involves those born between 1945 and 1965] for HCV antibody would have missed 36 of 128 of cases with detectable antibody and 26 of 105 (25%) of those with replicative HCV infection,” researchers noted.

In an interview with Infectious Disease Advisor, Dr Lyons said the study, “expands an already extensive literature showing that emergency departments are an ideal location for identification of patients with undiagnosed and untreated illnesses.  Though our article was specific to hepatitis C, the broader health services theme likely applies to any illness of interest.”

“Unfortunately EDs face numerous and difficult barriers to intervention for conditions that are not an immediate threat to individual health,” Dr Lyons explained.  “A barrier of particular importance is often the lack of follow-up care. This includes insufficient treatment capacity in the community and lack of easy and effective mechanisms to link patients to care and services.”

He said it would be helpful for specialists to recognize the importance of active and highly functional relationships with emergency departments to address the needs of patients who are as yet undiagnosed or not in care. 

“Specialists can even help to motivate emergency department providers and hospital administrators to take action to address important health issues such as undiagnosed Hepatitis C,” he added.

During the interview, Dr Lyons noted that it was important to recognize emergency departments differ in size, location and patient populations.  “The prevalence of undiagnosed Hepatitis C in many emergency departments may not be as high as was seen in this urban academic center that cares for many disadvantaged and underserved patients.  Nonetheless, given the remarkably high prevalence of Hepatitis C reported by this emergency department (and others), it seems reasonable to assume that the vast majority of U.S. emergency departments have sufficient levels of undiagnosed Hepatitis C to warrant a specialty-wide response,” Dr Lyons said.

Coauthor of the study Carl J Fichtenbaum, MD, Professor of Clinical Medicine at the Division of Infectious Diseases at the University of Cincinnati also spoke with IDA. “Hepatitis C is more prevalent than we thought, and the CDC recommendations of testing people born from 1945-1965 will miss a number of people with undiagnosed Hepatitis C (28%),” he said during the interview. “So I think infectious diseases physicians should be screening more for Hepatitis C since it has implications for preventing further spread and lowering the risk of progression of liver disease or development of cancer.”

Dr. Fichtenbaum also noted that, “103 persons had positive PCR for HCV indicating active replicative infection.  And if we only tested birth cohort using CDC recommendations, there would have been 25 persons with active infection that would have been missed.  This can lead to the ongoing spread of hepatitis C. This study strengthens the recommendations for more universal testing and treatment to reduce the spread of the epidemic”.

Reference

1. Lyons MS, Kunnathur VA, Rouster SD et al. Prevalence of diagnosed and undiagnosed hepatitis C in a midwestern urban emergency department. Clin Infect Dis. 2016;62(9):1066–71.