Annals of Emergency Medicine
Volume 62, Issue 6 , Pages A19-A21, December 2013
Ryan L. Nave (Special Contributor to Annals News & Perspective)
Section editor: Truman J. Milling, Jr, MD
It didn't take long after rolling out a new screening program for emergency physicians at the University of Alabama at Birmingham (UAB) to realize the scope and complexity of what has been called a silent killer for baby boomers: hepatitis C.
“We had previously estimated that somewhere between 3% and 5% of persons born between 1945 and 1965, who were unaware of their hepatitis C status, would be hepatitis C antibody positive,” said James Galbraith, MD, an emergency physician at UAB.
As it turned out, the prevalence was much, much higher than anyone at UAB had expected. After screening 40 baby-boomer patients that first day, 6 results were antibody positive for hepatitis C, a blood-borne viral disease that attacks the liver but remains dormant in the body for decades before symptoms appear, typically in the form of cirrhosis, liver disease, or liver cancer.
The 76 million people born between 1945 and 1965—also known as baby boomers—are especially at risk, accounting for three quarters of all hepatitis C infections in the United States. The crisis so alarmed health officials that it prompted the US Preventive Services Task Force in 2012 to recommend that all baby boomers be screened once for the disease.
The initial higher-than-anticipated prevalence rates caused some of the emergency physicians at UAB to believe the results might be a fluke, but these continued into the next days and weeks. As of October 1, the screening program's prevalence rate of approximately 13.5% remained unchanged. In the first 2 weeks after commencing the tests, UAB tested 524 baby boomers, and 70 of those patients' results were antibody positive for hepatitis C, Dr. Galbraith said.
With numbers like that, the department is on course to screen 15,000 patients in the first year. So far, Dr. Galbraith said the department is doing fine managing the testing itself, but he's concerned about looming challenges.
“We're really trying to revise what we're doing because we were estimating somewhere between 300 and 500 [hepatitis C–positive patients] identified in the first year, and now we're talking about 1,500. The benefits to screening are lost if you're not assisting patients and getting them linked into care,” Dr. Galbraith said.
He added: “Hepatitis C is a treatable and increasingly curable disease that disproportionately affects this population. So the clock is ticking for this baby boomer generation to get them into care and possibly even curative treatment.”
The Root of the Problem
According to Centers for Disease Control and Prevention (CDC) estimates, about 3.2 million people in the United States have chronic hepatitis C infection. Present and past injection drug users are most at risk for the infection, as are people with HIV—10% to 15% of whom are coinfected with hepatitis C—and people who received blood transfusions before 1992 when hepatitis C screening became widely available.
Infection rates for hepatitis peaked in the mid-1970s, around the time injection drug use in the United States was also at its highest levels. Around 1960, hepatitis rates increased even though hepatitis C was then known only as hepatitis non-A non-B. By the early 1990s, injection drug use and transfusion-related transmissions experienced steep declines. Since then, hepatitis C infection rates have decreased 90%, data show.
In the 2 decades since, many of those individuals who were at the greatest risk during the height of the hepatitis C infection may have stopped using injection drugs or simply forgotten about a transfusion they received during a routine surgery such as a cesarean section and do not realize they should be screened for hepatitis C.
CDC data also show that for every 100 people infected with hepatitis C, somewhere between 5 and 20 will develop cirrhosis during a 2- to 3-decade period, and between 1 and 5 will die from cirrhosis or liver cancer. One-time screening of all baby boomers could result in identifying 800,000 people with hepatitis C, the CDC said.
In August 2012, the CDC published “Recommendations for the Identification of Chronic Hepatitis C Virus Infection Among Persons Born During 1945-1965” in the agency's Morbidity and Mortality Weekly Report, which helped sound the alarm.
“Hepatitis C virus (HCV) is an increasing cause of morbidity and mortality in the United States. Many of the 2.7 [to] 3.9 million persons living with hepatitis C virus infection are unaware they are infected and do not receive care (e.g., education, counseling, and medical monitoring) and treatment. CDC estimates that although persons born during 1945 [to] 1965 comprise an estimated 27% of the population, they account for approximately three fourths of all hepatitis C virus infections in the United States, 73% of hepatitis C virus–associated mortality, and are at greatest risk for hepatocellular carcinoma and other (hepatitis C)–related liver disease,” the report states.
Additionally, the CDC said that with the advent of new therapies that can halt disease progression and provide a virologic cure in most persons, targeted testing and linkage to care for infected persons in this birth cohort is expected to reduce hepatitis C virus–related morbidity and mortality.
John W. Ward, MD, director of the CDC's Division of Viral Hepatitis, said, “A major priority for hepatitis prevention is screening to identify persons living with chronic hepatitis B and hepatitis C and linking them to care to reduce the disease and death from chronic infection.”
In 2012, Congress directed $10 million to Dr. Ward's division from the Prevention and Public Health Fund, part of the Patient Protection and Affordable Care Act, to improve testing for hepatitis B and C. More than 150 providers applied 30 funding awards for specialized screening of foreign-born populations and injection drug users and at federally qualified health centers.
Separately, UAB received funding from the CDC Foundation's Viral Hepatitis Action Coalition to screen 8,000 baby boomers for hepatitis C for 1 year. The screen itself involves a polymerase chain reaction test (patients may opt out of the screen, but that is rare) performed on blood already drawn. And even though UAB may ultimately screen more patients than physicians planned for, the paying for the tests is only one part of the equation.
“A lot of these baby boomers who ultimately need treatment for hepatitis C infection…also have other comorbid conditions that need to be treated just to make them able to tolerate the regimens for hepatitis C treatment; you know: things like diabetes, high blood pressure,” Dr. Galbraith said. “Approximately 50% of patients that we're diagnosing have publicly funded insurances like Medicaid, indigent-care insurances, or are uninsured, and that becomes a real challenge in trying to get these individuals linked into care.”
Learning From Experience
Emergency departments are good for diagnosing problems but are not the best option for providing long-term treatment. At UAB, that's where the hospital's 1917 Clinic comes in. The clinic, which served almost 2,000 patients in 2012, is Alabama's largest HIV health care facility. A few years ago, the clinic expanded its services to include hepatitis C testing.
Ricardo Franco, MD, a member of the 1917 Clinic's staff said the hepatitis C screening program attempts to use a similar model for care as the clinic. “Many of them have the emergency room as the only source to have health care access, and not being insured, that probably favors a life trajectory of not really paying attention to health expenses,” Dr. Franco said.
Dr. Galbraith, Dr. Franco's colleague at UAB, said data suggest that hepatitis C affects men more than women and disproportionately minorities and the uninsured. Blacks have hepatitis C infection rates twice that of the general population. Information from CDC in 2012 shows that between 2000 and 2011, the rate of hepatitis C among blacks increased by 27.3%; among Hispanics, by 21.4%. Also, American Indian/Alaska natives were doubly likely to develop a case of hepatitis C compared with the white population in 2011.
Corinna Dan, RN, MPH, a viral hepatitis policy advisor with the US Department of Health and Human Services' Office of HIV/AIDS and Infectious Disease Policy, said culture could sometimes be a barrier to treatment in minority communities. “There are many challenges, including very low awareness among communities and the providers who serve them, stigma related to having hepatitis C and the behaviors that most often lead to exposure—ie, injection drug use—[and] low rates of health insurance coverage, as well as limited access to health care providers who are trained to identify individuals at risk, manage, and treat chronic hepatitis C infection. An additional challenge in the African American community is that the previously available treatment for hepatitis C was not as effective in eliminating the virus in African Americans as it was for other racial and ethnic groups. This led to people deferring screening or not following up on referral to care because there was a sense that there was no treatment for them,” Ms. Dan wrote in an e-mail.
In addition to the limited infrastructure that exists for hepatitis C screening in general, lack of public education of the disease presents an additional barrier. At the same time, though, she sees opportunities. “There is very low public awareness of this condition, but there are more materials available now than there have been in the past, including some developed specifically for minority communities. There has not historically been a large investment in hepatitis C testing by public health entities; however, with the [US Preventive Services Task Force] screening recommendation now a “B” grade, screening will be covered for individuals with health insurance as a preventive health service free of cost sharing or copay under the Affordable Care Act.” She added, “The challenge we are faced with is educating community members to request the test and health care providers to recommend the test.”
Ms. Dan, of the US Department of Health and Human Services, said that a variety of strategies should be developed to increase awareness of hepatitis C and encourage people to be tested for the infection, and that EDs “can be part of the solution.”
“We are working across government to increase awareness of and appropriate screening for hepatitis C, including working with colleagues at the Health Resources and Services Administration, which supports many safety net providers, including community health centers and hospitals,” she said.
Dr. Galbraith is in agreement. “We are the safety net for our communities and, to me, if you can do some of these screenings, which are burdensome and costly, if you can find ways to cover the costs, and make these things happen in the background without disturbing the other competing priorities we have in the emergency department, then we're doing a good service not just for our individual patients but for our community.”
Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). The author has stated that no such relationships exist.
The views expressed in News and Perspective are those of the authors, and do not reflect the views and opinions of the American College of Emergency Physicians or the editorial board of Annals of Emergency Medicine.
© 2013 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.