Journal Highlight: Many Patients With Hepatitis C Are Undiagnosed

A study conducted at an urban emergency department has shown that hepatitis C testing misses up to 25% of unidentified infections, suggesting that universal testing may be better in identifying, treating, and preventing the spread of the virus.

While birth cohort testing patients born between 1945 and 1965 for hepatitis C virus can identify more undocumented cases than risk group testing alone, a recent study published in Clinical Infectious Diseases shows that as many as 25% of patients with hepatitis C go undetected beyond these targeted groups.

Yu-Hsiang Hsieh, PhD, Associate Professor at the Department of Emergency Medicine at Johns Hopkins University School of Medicine in Baltimore, MD and colleagues performed a seroprevalence study over the course of 8 weeks from June to August, 2013, at Johns Hopkins Emergency Department in Baltimore City, MD. The study analyzed patients older than age 17 who had blood left over from clinical purposes were tested for hepatitis C virus (HCV) antibodies. The researchers gathered past history of HCV infection and demographics from electronic medical records. Study results were unlinked from the identity of the patient whom the sample was available.

Of examined samples, 652, or 13.8% were antibody positive out of 4,713 patients. Undocumented HCV infections accounted for 31.3%, or 204 of the samples. Of these unknown infections, almost half would have been caught through birth cohort testing, and over a quarter would have been identified through risk-based testing. However, 25% of undocumented cases of HCV identified did not fit in either of these groups.

Current US Centers for Disease Control and Prevention testing guidelines for HCV recommend a single test for those born in the baby boomer birth cohort (1945-1965), anyone who presently or in the past has injected IV drugs, patients who are HIV positive, and those with medical conditions that may have exposed them through blood products, organ transplantation or long-term hemodialysis. Patients with alanine aminotransferase levels (ALT) that are persistently are not in normal range are also advised to be tested.

In an interview with Infectious Disease Advisor, Dr Hsieh said that, “Even though current Centers for Disease Control and Prevention guidelines do not recommend hepatitis C virus screening of individuals outside of the baby boomer birth cohort, in settings such as urban emergency departments or other medical care settings, hepatitis C virus screening of patients who were born outside of the baby boomer birth cohort should be considered.”

Dr Hsieh said that since the study had been conducted, steps have been taken to gather additional data. “Based on our finding from the identity-unlinked seroprevalence study, we began an emergency department-based hepatitis C virus screening program in the emergency department at The Johns Hopkins Hospital in November 2015,” he said.

Preliminary data demonstrated that 3% of Emergency Department patients who are outside of the baby boomer birth cohort and do not have documented hepatitis C virus infection have HCV antibody. This matches with the study’s findings, which he said, “showed that 2.6 percent of Emergency Department patients at The Johns Hopkins Hospital in 2013 had undocumented hepatitis C virus antibody in the nonbaby boomer birth cohort.”

“Given an estimated 7727 unique ED patients with HCV infection in a 1-year period, birth cohort plus risk-based testing would identify 1815 undocumented infections, and universal testing would identify an additional 526 HCV-infected persons,” the researchers wrote in the study.

Co-author of the study David Thomas, MD, MPH, and Stanhope Bayne-Jones Professor of Medicine and Director in the Division of Infectious Diseases at the Johns Hopkins University School of Medicine also spoke with IDA, and added that, “the report indicates that in some settings like Baltimore, where hepatitis C is highly prevalent, hepatitis C testing might need to be expanded to people outside the birth cohort, even to those who do not acknowledge a well-accepted risk factor.

In a Johns Hopkins press release, Thomas C Quinn, Professor of Medicine and Pathology at the Johns Hopkins University School of Medicine said, ““This is an infection that can now be cured if detected early, rendering people noninfectious and thereby preventing the dire consequences that are associated with the virus. However, we found a large proportion of undocumented, undiagnosed hepatitis C infection in the population attending this ED.”

Dr Quinn spoke briefly with IDA and explained, “The basic message for everyone is that universal screening for hepatitis C should be recommended and implemented in all urban emergency departments, since a treatment and cure are now available.”


1. Hsieh YH, Rothman RE, Laeyendecker OB et al. Evaluation of the Centers for Disease Control and Prevention recommendations for hepatitis C virus testing in an urban emergency department. Clin Infect Dis. 2016;62(9):1059–65.