March 20, 2014
Baby boomers account for about 75% of hepatitis C infections in the United States, but most don't know they are infected. Now, several studies have shown that the emergency department is an ideal place to screen this population.
Hepatitis C disproportionately affects nonwhites, Medicaid recipients, the uninsured, and people of lower economic status. These are populations known to use the emergency department as a primary source of medical care.
"We now have data from 2 different sites in the country that are doing hepatitis C screening of baby boomers in the emergency department," said James Galbraith, MD, from the University of Alabama at Birmingham.
"We are showing similar yields of previously unknown hepatitis C infection in 2 different demographic groups. The important thing is that such screening is very feasible," he told Medscape Medical News.
The screening of baby boomers has been done in the Alabama emergency department since September 2013. Dr. Galbraith presented preliminary findings at The Liver Meeting in 2013, as reported at the time by Medscape Medical News.
He presented additional data from his continuing experience in Alabama and new data from the Memorial Hermann–Texas Medical Center, in Houston, at the International Conference on Viral Hepatitis 2014 in New York City.
"Memorial Hermann has been screening baby boomers for hepatitis C using a little different methodology, but they have had very similar results," Dr. Galbraith said.
“The important thing is that such screening is very feasible.”
In Alabama, all emergency patients get a primary assessment by a nurse. If they were born between 1945 and 1965, they are asked if they have ever been tested for hepatitis C and, if so, what was the result.
If they do not know the answer to either question, they are informed of the Centers for Disease Control and Prevention (CDC) 2012 recommendation that all baby boomers get a 1-time screening test for hepatitis C, and that such a test will be performed during their emergency department visit unless they decline.
If they do not opt out, the electronic record automates an order for a hepatitis C screen that is performed in the emergency department lab, using the Abbott ARCHITECT anti-hepatitis C assay, which returns a result in 29 minutes.
If required, linkage to care starts 2 or 3 days later with a phone call to the patient from the linkage-to-care coordinator, Dr. Galbraith explained.
The procedure at Memorial Hermann is somewhat different.
The decision to offer hepatitis C screening is made by residents and physicians on the basis of the patient's history and physical exam. The screening tests, if done, are batched and run once a day, not while the patient is actually in the emergency department. People who test positive get a letter in the mail reporting their result and then a phone call from a nurse who provides linkage to care.
Despite these procedural differences, prevalence rates are similar at the 2 sites, Dr. Galbraith said.
Of the 1421 baby boomers screened at Memorial Hermann, 9.9% tested positive for the hepatitis C antibody. Of the 1259 screened at Alabama, 11.1% tested positive.
Black Patients at Greatest Risk
At Memorial Hermann, 61% of people testing positive were men; at Alabama, 65% were. The higher prevalence in men is the trend "we see nationally," Dr. Galbraith said.
The prevalence is also higher in black people. At Memorial Hermann, 51% of patients testing positive were black; at Alabama, 61% were. White patients accounted for 37% of patients testing positive at both emergency departments.
For baby boomers tested at Alabama, the prevalence of positive results was higher in black than in white patients (13.3% vs 8.0%).
"This definitely fits with what we know. Based on data from the CDC, black people are disproportionately affected and are accounting for a high number of individuals testing positive," he said.
Virtually all of the patients at both sites were uninsured or were covered by Medicaid. "Only 11% of antibody-positive patients at Alabama had private insurance," Dr. Galbraith reported.
High Cost of Screening
Such screening programs do come with a high cost. At Alabama, the annual cost of screening was $250,000, which could be a barrier to widespread baby boomer screening in the United States.
This study reinforces the feasibility of birth-cohort-based hepatitis C screening in the academic emergency department setting, said José Zuniga, PhD, MPH, president of the International Association of Providers of AIDS Care.
However, "it also highlights some of the obstacles, including unreimbursed costs and the need to make adjustments in the clinical practice culture to convince already busy physicians and nurses to add hepatitis C screening to their many responsibilities," Dr. Zuniga told for Medscape Medical News.
The study was funded by the Centers for Disease Control Foundation and Gilead Focus. Dr. Galbraith and Dr. Zuniga have disclosed no relevant financial relationships.
International Conference on Viral Hepatitis (ICVH) 2014: Abstract 59. Presented March 17, 2014.