Tackling hepatitis C infection through emergency department testing
Hepatitis C testing in the emergency department at the University of Alabama at Birmingham Hospital has discovered 2,436 positive cases since testing began in September 2013.
UAB physicians say identifying those patients and linking them to appropriate therapy is one successful step in an effort to reduce the infection rate locally. The program can also serve as a model that could one day eradicate hepatitis C in the United States if done on a national scale.
The testing began as part of a Centers for Disease Control and Prevention initiative designed to identify patients with hepatitis C and get those patients into treatment. UAB began by testing the most at-risk populations—the baby boomer generation and those with a history of injection drug use—who presented for any reason at UAB Hospital's emergency department. In September 2015, UAB expanded the testing to include all patients at the ED, ages 18-75.
"We're finding that about 8 percent of those tested have a positive result," said James Galbraith, M.D., associate professor in the Department of Emergency Medicine, part of the UAB School of Medicine. "The overall target is the estimated 3.2 million people in the United States who have chronic hepatitis C virus infection—many of whom are unaware they are infected because they don't look or feel sick."
Hepatitis C is a contagious liver disease that ranges in severity from a mild illness lasting a few weeks to a serious, lifelong illness that attacks the liver. It is caused by a virus, referred to as HCV, which is spread primarily through contact with the blood of an infected person. Today, most people acquire HCV through sharing needles or other equipment used to inject drugs. Prior to 1992, the virus could be spread through blood transfusion or organ transplants, although widespread screening has now virtually eliminated that risk.
The antibody test given at the UAB ED simply indicates exposure to HCV at some prior point in a person's life. About 25 percent of those who test positive have actually cleared the virus and are not infected with HCV. A second test, also given at the ED, can confirm those with a positive infection with results available in about a week.
"Increasing awareness is the key," Galbraith said. "Only about half of those with HCV nationwide know they are infected. We have options for treating and curing HCV, but we have to identify the infection first."
The recent programmatic change to universal HCV testing in the UAB ED has identified a large number of HCV-infected patients outside of the baby boomer generation.
"We found an infection rate of 12 percent for white individuals born after 1965," Galbraith said. "The virus is most commonly transmitted by injectable drug use, so that population has become a key demographic to identify."
The HCV testing program combines identification of those with infection with linkage to appropriate antiviral treatment services through the UAB Liver Center, Liver Transplant Clinic and 1917 Liver Clinic. A linkage coordinator helps those who test positive establish a primary care physician to maintain consistent health care throughout the progression of their disease.
"Not only does the testing help link these patients to treatment for hepatitis, it also gives us an opportunity to reach out and provide therapy for addiction," Galbraith said. "We think we are making a huge difference in this population. We think if this type of type of screening were done nationally on a large scale, we could potentially eradicate HCV in 20 years."
Galbraith says there is no national policy to conduct screening in secondary care settings, including the ED. He believes the emergency department is a unique and critical location for such programs.
"Most screening is done in the primary care setting, which misses those individuals who do not have a relationship with a primary care physician, a common occurrence in this population," he said. "Coupled with test reimbursement issues, these are major barriers to establishing a national screening program and possibly eradicating the disease."