Birth Cohort Screening for Chronic Hepatitis During Colonoscopy Appointments

The American Journal of Gastroenterology

Dawn M Sears MD, Dan C Cohen MD, Kimberly Ackerman DO, Jessica E Ma, Juhee Song PhD

Am J Gastroenterol. 2013;108(6):981-989

Abstract and Introduction

Abstract

Objectives: More than 70% of infections with hepatitis C viruses (HCV) occur among people born between 1945 and 1965 (baby boomers). The US Centers for Disease Control estimate that 70% of people with chronic hepatitis are not aware that they are infected with a virus. We performed a prospective trial to determine whether people born during this time period would accept testing for chronic viral infection (hepatitis B virus (HBV) and HCV) during routine colonoscopies. We also evaluated acceptance and efficacy of screening for immunity to hepatitis A (HAV) and B viruses.

Methods: During a 3-month period, 500 people, 50–65 years old, who received a colonoscopy were offered a test for viral hepatitis. Patients answered questions about vaccination, exposure, diagnoses, and risk factors related to viral hepatitis, and blood samples were collected. Patients who tested positive for antibodies to HCV or hepatitis B surface antigen (HBsAg) were contacted for further testing and possible therapy. Patients without immunity to HAV or HBV were offered vaccinations.

Results: Three hundred and seventy-six people (158 men) agreed to be tested. Four were found to have antibodies against HCV and one had detectable virus. None of the patients tested positive for HBsAg; 136 (36%) had at least one risk factor for chronic hepatitis and 31 (8%) had multiple risk factors. Three hundred and fifteen patients (84%) were not immune to HAV, HBV, or both viruses.

Conclusions: It is possible to screen patients for viral hepatitis during visits for routine colonoscopy. This approach can identify individuals with undiagnosed chronic HBV and HCV infections who could benefit from education, vaccination, or therapy.

Introduction

Chronic viral hepatitis is a major silent epidemic in the United States. Over 5 million Americans have chronic hepatitis C virus (HCV) or hepatitis B virus (HBV) infection.^[1,2] The Center for Disease Control (CDC) estimated that over 70% of chronic HCV infection is undiagnosed. It is estimated that 1 in 30 Americans born between 1945 and 1965, "the Baby Boomers", are infected with HCV.^[3] Therefore, the CDC is now recommending one time screening of all baby boomers for chronic hepatitis C. HCV infection now supersedes HIV as a cause of death in the United States. Mortality from chronic HCV infection is estimated to double by the year 2020 and triple by the year 2030.^[4,5] Although required HBV vaccinations have decreased the prevalence of HBV among children, possibly due to immigration patterns, the prevalence of HBV among adults in the United States has remained essentially unchanged at 0.27%.^[2]

Previously, it was recommended to screen only high-risk individuals (with the most common risk factor for HCV being intravenous (IV) drug use) or patients with abnormal liver tests. To date, the majority of community hepatitis screening programs have focused on drug treatment centers, homeless shelters, and prisons.^[6–11] These patients generally have poor access to healthcare and are less invested in their health, making treatment and/or follow-up difficult. More importantly, targeted screening programs focusing on high-risk populations fail to identify the majority of undiagnosed chronic viral hepatitis infections, 66–70% of which are found in Americans born between 1945 and 1965. Baby boomers commonly contracted HCV from pre-1992 blood transfusions or past IV drug use.^[2] Quickly finding and treating patients in this age range is imperative as patients older than 65 years are more likely to develop severe fibrosis and are four times less likely to complete antiviral therapy due to adverse side effects.^[12–14]

As with chronic viral hepatitis, acute viral hepatitis due to hepatitis A virus (HAV) and HBV represents a large epidemiologic problem. Acute HAV infection is the leading cause of acute hepatitis worldwide. Adults who become ill with this food-borne infection miss an average of 30 days of work due to jaundice.^[15] Despite widespread availability of HAV and HBV vaccinations, only 10–50% of adults have antibodies against these viruses.^[16–19] Therefore, there is a significant unmet need to systematically incorporate risk assessment, screening, vaccination, and treatment of viral hepatitis into the adult health-care delivery system.

Gastroenterologists are in a distinctive position as they are both experts on viral hepatitis and perform screening colonoscopies. Currently, routine screening colonoscopies are recommended for individuals starting at age 50, with recommended follow-up colonoscopies at 5- or 10-year intervals in the majority of cases.^[20] Furthermore, patients who present for screening colonoscopies generally have access to healthcare and are often health-insured. Two recent studies have found that birth cohort screening for viral hepatitis is cost effective regardless of risk factors.^[21,22] This represents a unique opportunity for gastroenterologists to conduct screening for viral hepatitis on baby boomers when they present for screening colonoscopies.

Our study sought to evaluate the feasibility and patient acceptance of screening baby boomers who present for colonoscopy for chronic HCV and HBV infection, and HAV and HBV immunity. Additionally, we assessed the effectiveness of this screening method in achieving substantial patient follow-up for the treatment of chronic hepatitis and vaccinations to prevent acute hepatitis.

Methods

Design

During a 3-month period, from October 2010 to January 2011, all insured patients aged 50 to 65 years old (falling into a narrower birth cohort 1945–1960) scheduled for outpatient colonoscopy at Scott & White Healthcare and without prior diagnosis of viral hepatitis were offered participation in the study. Study information was mailed to all eligible patients with their bowel preparation instructions. Packets included information about viral hepatitis and details of the study, including need for blood testing, explanation of results, and possible need for follow-up testing or vaccination. On the day of procedure, a research nurse met with each individual patient in a private examination room before entry to the endoscopy suite. During the meeting, the patient completed the Institutional Review Board (IRB)-mandated consent form stressing the fact that the study did not pay for viral hepatitis screening or vaccination (they were also made aware that their insurance would be billed separately for these services if they wished to participate). Patients filled out a questionnaire regarding (1) exposure and vaccination of hepatitis A and B viruses, (2) existing diagnosis of chronic hepatitis B and/or C viruses, and (3) positive risk factors for chronic hepatitis B and C viruses. Questions regarding risk factors included IV drug use, sexual habits, tattoo placement, receiving of blood transfusions, and imprisonment among other things (see Appendix for questionnaire). Even if a patient had no stated risk factors, they were able to choose to undergo further testing for chronic hepatitis or immunity if desired. No prior knowledge of any of the patient's liver function testing was reviewed. Patients could select any or all viral hepatitis tests including hepatitis A antibody, hepatitis B surface antibody and/or antigen, and hepatitis C antibody. Patient-selected screening was offered as some patients already knew the status of some of their markers. In the endoscopy suite blood was drawn from pre-procedural IV site. Two to four weeks after screening completion, results were mailed with follow-up instructions. Six and twelve months later, data were collected on follow-up rates utilizing review of electronic medical records and telephone interviews.

Study Setting

Study took place within the Gastroenterology Department of Scott & White Healthcare. Scott & White is a non-profit health-care institute and level 1 trauma center located in Temple, Texas. It encompasses a 29,000 square mile service area and treats over a half million patients per year. Our patients typically take advantage of preventative services available through both the Scott & White Healthcare system, as well as the Central Texas Veterans Administration demonstrated by the fact that 65% of 50–65 year olds have received screening colonoscopies.

Study Population

Patients aged 50 to 65 years (born between 1945–1960) without known diagnosis of chronic hepatitis B and/or C scheduled for colonoscopy from the months of October 2010 to January 2011 were invited to enroll into the study. Those excluded from study participation were the uninsured and those unable to consent.

Laboratory Testing

Peripheral blood draw samples from the consented 376 patients were sent for anti-HCV, hepatitis B surface antigen (HbsAg), hepatitis B surface antibody, and/or hepatitis A total antibody testing. Testing was performed on the Abbott Axsym System (Abbott Laboratories, Chicago, IL) according to the manufacturer's recommendations. Patient results were entered into the Scott & White electronic medical record, and then delivered to study personnel.

Definitions

(1) If a patient was discovered to be hepatitis B surface antigen positive, this was defined as possible exposure to viral hepatitis B and in need of further testing to determine whether chronic infection was present. (2) If a patient was discovered to be hepatitis C antibody positive, this was defined as potential exposure to viral hepatitis C, and follow-up PCR was reflexively ordered. (3) If a patient was discovered to be hepatitis A antibody positive, this was defined as being immune to the virus, therefore not needing further assessment. (4) If a patient was found to be hepatitis B surface antibody positive, this was defined as immune to hepatitis B and no further assessment was needed. (5) If a patient was discovered to be hepatitis A and/or B antibody negative, this was defined as vulnerability to the viruses. Patients were therefore offered vaccination series.

Follow-up

Two to four weeks after screening completion, results were mailed with follow-up instructions. Those not immune to hepatitis A and/or B were offered vaccination. Those infected with hepatitis B and/or C were scheduled for a liver clinic appointment to discuss treatment and options. Those with "inadequate blood draw" were informed of such and advised to seek further screening through their primary care physicians, if they desired to do so. Six and twelve months later, data were collected on follow-up rates utilizing electronic medical record including vaccination dates and follow-up appointment notes.

Statistical Analysis

All variables including demographic and risk factors were summarized by frequency (percentage) for entire group, for those who required vaccination among study participants, and according to vaccination status. Among those who required vaccination, χ ² test or Fisher's exact test was performed to compare those who were vaccinated with those who were not vaccinated in each variable. Univariate and multivariable logistic regression analyses were utilized to identify factors associated with increased odds of getting vaccination. P value of less than 0.05 indicated a statistical significance. SAS 9.2 (SAS Institute INC, Cary, NC) was used for data analysis.

Results

Chronic Hepatitis B and C

A total of 500 patients were consecutively offered participation in the study. Of those, 17 (4.5%) patients had a known diagnosis of chronic hepatitis C, making our total number of eligible patients 483. Three hundred seventy-six (78%) of eligible patients agreed to participate in the study and completed our risk factor questionnaire (see Figure 1). Of the 376 participants, 158 (42%) were men. There were 297 (80%) Caucasians and 76 (20%) non-Caucasians (45 (12%) African Americans, 26 (7%) Hispanics, 3 (0.8%) Asian and Pacific Islanders) enrolled in the study (see Table 1 ). Only 36 of our patients were born outside the United States.

Table 1.  Demographic characteristics^a

Variable	Who participated (N=376)	Who required vaccination (N=315)	Who were vaccinated (N=51)	Who were not vaccinated (N=264)	P valueb
Age (years) c,d
50–55	169 (47%)	141 (46%)	24 (52%)	117 (45%)	0.29
56–60	102 (28%)	82 (27%)	14 (30%)	68 (26%)
61–65	92 (25%)	82 (27%)	8 (17%)	74 (29%)
Gender
Male	158 (42%)	137 (43%)	22 (43%)	115 (44%)	0.96
Female	218 (58%)	178 (57%)	29 (57%)	149 (56%)
Race e
Caucasian	297 (80%)	257 (82%)	46 (90%)	211 (81%)	0.11
Non-Caucasian	76 (20%)	55 (18%)	5 (10%)	50 (19%)

The demographics of those who would benefit from vaccination did not differ from baseline demographics. The demographics of those who completed vaccinations did not differ from those who did not complete vaccinations.

^aFrequencies and percentages were presented.

^bWho were vaccinated and who were not vaccinated groups were compared.

^cFrequency missing for who participated=13.

^dFrequency missing for who required vaccination=10.

^eFrequency missing=3.

Figure 1. Study flow chart. This flow chart outlines the findings of chronic viral hepatitis (Hep) screening for all patients invited into the study. Hep B antigen test was not done for seven patients. Hep C antibody test was not done for five patients. Frequencies; percentages (95% confidence interval (CI) for the percentages) were presented.

Thirty patients had inadequate blood draws (due to lack of quantity of blood to run assays), thus data for chronic viral hepatitis infection were available for 346 patients. Four patients (percentage (95% confidence interval for the percentage) 1.2% (0.3–3.0%)) were found to be anti-HCV positive. No patients were found to have HBsAg. All four patients who were anti-HCV positive complied with HCV PCR testing and follow-up within the 12-month follow-up time monitored. Ultimately, only 1 patient had detectable virus. He is following up in the liver clinic regularly, has been vaccinated against hepatitis A and B, has stopped alcohol, is eating healthier, and is awaiting non-interferon based therapy for his genotype 1 virus. None of the four patients with HCV-antibody positivity were know to have a history of any liver abnormalities or hepatitis.

Of the 376 patients who filled out the risk factor questionnaires before blood draw, 136 (36%) had at least one risk factor for chronic hepatitis and 31 (8%) had multiple risk factors (see Table 2 ). High-risk sexual activity and tattoo placed before the year 2000 were the most common risk factors, 29 (8%) patients, followed by injecting or snorting drugs, 26 (7%) patient. The risk factors of having HIV or hemophilia were not found in our study population. Two hundred and forty (64%) of patients had no risk factors for chronic HCV or HBV (see Table 3 ). All four participants who were anti-HCV positive had at least one risk factor.

Table 2.  Self-reported risk factor analysis^a

Variable	Who participated (N=376) (%)	Who required vaccination (N=315) (%)	Who were vaccinated (N=51) (%)	Who were not vaccinated (N=264) (%)	P valueb
Number of Risk
0	240 (64)	205 (65)	36 (71)	169 (64)	0.51
1	105 (28)	86 (27)	11 (22)	75 (28)
2	19 (5)	15 (5)	4 (8)	11 (4)
3	7 (2)	5 (2)	0 (0)	5 (2)
4 or more	5 (1)	4 (1)	0 (0)	4 (2)

The number of risk factors did not differ between groups.

^aFrequencies and percentages were presented.

^bWho were vaccinated and who were not vaccinated groups were compared.

Table 3.  Risk factor analysis for entire group

Type	Frequency (%)
Have HIV	0 (0%)
Have Hemophilia and received clotting factors before 1987	0 (0%)
Received an organ transplant before 1992	2 (1%)
Received dialysis	3 (1%)
Sexual partner with hepatitis B or C	10 (3%)
Health care worker who has been stuck with a needle	14 (4%)
Been in jail more than 2 days
Received a blood transfusion before 1992	24 (6%)
Ever injected or snort a drug	26 (7%)
Have another risk factor which you believe puts you at risk for chronic hepatitis B or C	27 (7%)
Tattoo placed before 2000	29 (8%)
Have sexually transmitted diseases or greater than 20 sexual partners in your life or other high risk sexual behavior	29 (8%)
No risk factors but want to be screened	240 (64%)

Patients could denote multiple risk factors, therefore the total absolute number is higher than 376.

Hepatitis A and B Immunity

Six patients declined HAV and HBV immunity testing, thus our total number of patients checked for immunity was 340 (see Figure 2). Three hundred and fifteen (93%) patients were not immune to HAV, HBV, or both. Two hundred and forty (71%) patients were found to be HAV antibody negative and 283 (83%) were found to be HBV antibody negative.

Figure 2. Vaccination flow chart. Three hundred and fifteen (84%) of patients did not have full antibody protection against both hepatitis (Hep) A and Hep B. Fifty-one (16%) ultimately completed vaccination within 1 year of follow-up. Only available test result was used to determine the requirement of vaccination (e.g., for Hep A positive and Hep B test was not done, then classified as no vaccination required. For Hep A negative and Hep B test was not done, then classified as Hep A only required). Frequencies; percentages (95% confidence interval (CI) for the percentages) were presented.

At both 6 and 12 months electronic medical record chart review was performed to assess vaccination compliance. Patients were deemed "Vaccination Complete" if they had vaccination clinic records from either two shots for hepatitis A or three shots for hepatitis B in that time period. At the conclusion of the study 51 patients (percentage (95% confidence interval for the percentage), 16.2% (12.3–20.7%) of those vulnerable) had completed the offered vaccinations at a Scott & White Vaccination clinic (Figure 2). There was no difference in the baseline demographics ( Table 1 ), number or type of hepatitis risk factors between those who completed vaccinations and those who did not ( Table 2 ). Univariate logistic regression analyses did not identify any significant factors associated with increased odds of getting vaccination (results not shown, all P values were greater than 0.05). Multivariable logistic regression selected by stepwise selection did not include any of factors as significant factors.

Patients were offered vaccination solely based on having a negative antibody. No known history of occupation, specific risk, liver function, history of viral hepatitis, or underlying liver disease was considered. Patients were encouraged to discuss this more fully with their primary care physicians if they had specific concerns regarding vaccinations. This is in compliance with the CDC's recommendation that "anyone who wishes to be protected from hepatitis" be offered vaccination.

Discussion

To our knowledge this study is the first to assess the possibility of combining colonoscopy with screening for viral hepatitis in patients born between 1945 and 1965, the baby boomers. To date, the majority of viral hepatitis screening programs have focused on high-risk patient populations including STD clinics, immigration centers, drug treatment centers, homeless shelters, and prisons.^[6-11] However, the US preventative task force concluded that there is no evidence that screening high-risk individuals leads to improved long-term health outcome.^[23] The CDC has announced the recommendation of one time screening of all baby boomers for chronic hepatitis C. Discovery of the most appropriate venue to feasibly accomplish this daunting task is now in the forefront.

The few studies that followed high-risk patients from screening to treatment showed limited implementation of treatment and vaccination recommendations. In fact, only 21% of patients found to have chronic hepatitis through these high-yield screening programs ultimately received antiviral therapy.^[24] The reasons for the lack of follow-up throughout therapy are numerous and include poor access to healthcare, unreliable behavior, language barriers, transportation issues, and contraindications to therapy.^[7,11] By screening patients who are insured, have taken a bowel preparation, and requires a driver in order to appear for an appointment, many of these barriers are factored out.

Acceptance of Viral Hepatitis Screening

The aim of our study was twofold. First we sought assessment of the feasibility and patient acceptance of screening for chronic HCV and HBV infection, and HAV and HBV immunity during colonoscopy. We hypothesized that patients who present for outpatient colonoscopies have access to healthcare and are more likely to accept screening for viral hepatitis. As predicted, we were able to demonstrate that acceptance of screening for viral hepatitis in baby boomers presenting for colonoscopy was high, 376/483 (78%). Moreover, all participants who agreed to be screened also agreed to take a risk factor questionnaire before having their blood drawn.

Studies assessing the acceptance of general viral hepatitis screening in the primary care setting have been shown to be low, largely due to patient reluctance to discuss risk factors coupled with the lack of primary care physician awareness of patients with chronic hepatitis in their practice.^[8,25-27] Additionally, further referral to specialists (gastroenterologists and infectious disease physicians) for treatment and management has been shown to pose a barrier to screening acceptance. In a large screening study, only 39% of patients found to have HCV antibodies kept the referral to a hepatologist.^[28] However, our high percentage of screening acceptance was not entirely surprising. A 2008 study on veteran's affairs patients, which found that 73% of patients screened positive for hepatitis C antibodies, complied with follow-up in a dedicated hepatitis C clinic.^[28]

We believe that the setting in which viral hepatitis screening took place had an integral role in attaining a high patient acceptance. First, information mailed to patients before their visit allowed time for patients to learn about viral hepatitis. Second, patients appeared relieved by the fact that no additional needle sticks would be necessary and that the IV site placed for their colonoscopy would suffice for blood collection for hepatitis screening. Third, patients were reassured that the same doctors who would be performing their colonoscopies are the experts on viral hepatitis and would therefore be the ones checking their viral hepatitis screening results and making further recommendations regarding treatment, vaccination, and follow-up. Further studies to evaluate what impact the outpatient colonoscopy setting has on viral hepatitis screening acceptance are necessary to verify this information.

Follow-up

Our second aim was to assess the effectiveness of this screening method in achieving substantial patient follow-up for treatment of chronic viral hepatitis and vaccinations to prevent acute viral hepatitis. We hypothesized that patients who present for outpatient colonoscopy are innately invested in their health and therefore would be more likely to adhere to follow-up recommendations, specifically HCV RNA testing and vaccination for HAV and HBV.

Chronic Viral Hepatitis

Chronic Hepatitis C. Out of 346 participants with adequate blood draws, we found only four patients with anti-HCV antibodies. All four patients with anti-HCV positivity were followed up with HCV PCR testing. With the estimated prevalence of chronic HCV infection among baby boomers being 1 in 30, we expected ~17 patients to be HCV antibody positive. We found 17 patients who already knew that they were infected with hepatitis C. This resulted in the additional capture of only one new case of chronic hepatitis C. The usual prevalence of chronic hepatitis C is despite the fact that our patient population at Scott & White Healthcare (a non-urban hospital catering to small communities in central Texas) would have a perceived low risk for chronic hepatitis. This notion is reinforced by the low prevalence of high-risk behaviors on our questionnaire, as only 7% reported a history of injection drug use, the most common risk factor for chronic HCV infection ( Table 3). As a group, baby boomers have a prevalence of prior drug use (including one time experiment) of 40–60%. In some recent studies, ~10% of baby boomers state that they have used illegal drugs within the last year.^[29] Demographically, one might expect our population to have a lower prevalence for chronic hepatitis C, however, our actual prevalence was exactly the predicted norm for all baby boomers. Therefore, we believe that no community is immune to undiagnosed chronic hepatitis C.

Chronic Hepatitis B. No patients tested positive for HBsAg. Scott & White Healthcare in Temple has a low prevalence of chronic hepatitis B. Our study population also has a very low racial diversity: 80% Caucasian, 12.1% African-American, 7% Hispanic, and 0.8% Asian and Pacific Islanders. Less than 10% of our patients were born outside the United States (mostly Mexico). With a very low pre-test probability, we only screened with hepatitis B surface antigen. In low-risk populations, screening with hepatitis B core antibody usually results in false-positive findings and ultimately more expensive follow-up laboratory work. Hepatitis B core antibody should be combined with hepatitis B surface antibody for accurate screening for current or past hepatitis B infections in most screening situations. However, in our population, we felt that the false-positive risks outweighed the small potential benefit of discovering a patient with hepatitis B core positivity and surface antigen negativity.

Hepatitis A and B Immunity. With regard to immunity to HAV and HBV, we found that 315 (84%) of our participants might benefit from least one vaccination. Of those 315 patients, only 51 (16%) had documented complete vaccination series follow-up in our electronic medical records at 1-year follow-up. This low number of follow-up was contrary to what we expected. We believe some of this can be explained by our open access screening colonoscopy system. Many of our patients travel several hours to Scott & White Healthcare for their outpatient colonoscopies. These patients may have found it more convenient to obtain these multi-appointment vaccinations from their primary care physicians rather than in our gastroenterology clinic in Temple, Texas. Also, the timing of our study was during the height of an economic downturn during which many patients are known to have avoided preventative care appointments and procedures. Repeating this study in a narrowed geographic focus with more than a single letter recommending vaccination might lead to better vaccination completion rates.

Economics

Acute and chronic viral hepatitis are costly diseases, and cirrhosis caused by chronic HCV infection represents the most common need for liver transplant in the United States.^[30] The economic burden of chronic hepatitis for an individual is great: chronic hepatitis ($8,000), cirrhosis ($10,000), liver cancer ($40,000), and liver transplant ($200,000).^[31–34] The annual cost of chronic HCV in the United States includes $24 million for outpatient physician services and $530 million for antiviral treatments.^[31] In addition, an annual economic burden for acute hepatitis A is $500 million.^[35] Efforts to increase vaccinations, screening, and early treatment for hepatitis are cost effective for patients with or without risk factors for viral hepatitis.^{[21,22,30,36–38]} With the advent of the new protease inhibitors, treatment can achieve cure in 65–90% of treatment-naive patients who complete therapy, and new therapy is even more promising in the near future. Additionally, treatment of chronic HCV infection reduces lifetime risk of hepatocellular carcinoma by 10% and improves all cause mortality.^[39] Thus, there is potential significant cost savings from screening with a $43 hepatitis A antibody, $35 hepatitis B surface antigen, or $25 hepatitis C antibody, followed by a $100 hepatitis A and $60 hepatitis B vaccine series.

Limitations of Our Study

There are several limitations to our study. The low-risk factor prevalence, exclusion of the uninsured and limited demographics within our population likely muted the potential disease capture rate for this technique of screening for chronic viral hepatitis. If this study were to be reproduced in an urban center with higher prevalence of risk factors and ethnic diversity, higher capture rates of previously undiagnosed hepatitis infections would be expected. Our high patient pre-test knowledge of viral hepatitis status speaks of the ongoing community screening at both Scott & White Healthcare and our Central Texas Veterans Administration. However, it probably blunted the capture rate for this technique in our community. It can be argued that combining screening for hepatitis with outpatient colonoscopy may not capture an adequate number of patients requiring screening. However, now that it has been proven that colonoscopy is reduces mortality by 53%, it is possible that more patients will be referred for screening colonoscopy.^[40] Additionally, our study was conducted in a non-urban setting and the acceptance of our patients to be screened for viral hepatitis during outpatient colonoscopy may not generalize to a more urban setting with a more diverse ethnic population.

Finally, although our screening acceptance rate was 78%, we are uncertain as to the full reason for 22% to decline participation. We did not collect formal data on these patients until the final month of enrollment. We know that all were aged 50–65 and had medical funding sources. Most patients expressed uncertainty regarding medical insurance coverage (the time period of the study crossed that calendar year and many patients had not met their annual out of pocket deductibles). A smaller group of patients were uncomfortable filling out potentially embarrassing risk factor assessments. The remaining decliners either did not participate in research or did not believe that they had any risk factors or need testing. Quantitatively describing why all eligible patients declined would be interesting and may further aid in program development for screening for viral hepatitis in this venue.

Practical Implementation

If this technique of combining viral hepatitis screening with colonoscopy were to be instituted, plans for a nurse to explain viral hepatitis during bowel preparation instruction could be easily incorporated into practice. From our experience (almost 10% of samples being inadequate), we would recommend two vials of blood to be drawn from the IV site placed in the pre-endoscopy unit. Blood results from hepatitis screening could be delivered at the same time and with same mechanism, as polypectomy results are currently conveyed (often letters for expected results and telephone calls for unexpected or serious results). Therefore, extra appointments and new delivery systems would not be needed, however, broader nursing education and a slightly extended time spent with each patient would be necessary. The service of hepatitis screening is completely separate and should be billed to insurance as a unique issue. We did not follow-up with reimbursement rates for hepatitis screenings and vaccinations in our study population. However, we did have an agreement with our self-funded Scott & White Health Plan to pay for the screenings and vaccinations for those patients on Scott & White Health Plan (42% of our screened population- data not shown). If this mechanism were instituted on a larger scale willingness-to-pay would need to be explored further to assure feasibility.

With the recommendation for one time hepatitis screening of over 80 million baby boomers in the United States, utilizing an existing health-care screening system to deliver this service is highly desirable. As gastroenterologists, we see most baby boomers at least once and we also understand viral hepatitis. Incorporating viral hepatitis screening into colorectal cancer screening has the potential to be an easily instituted mass-screening mechanism. We hypothesize that this strategy will focus our limited national healthcare resources on those patients who are most likely to appear for follow-up testing and ultimately curative therapy. This will have to be explored at other diverse centers to determine the validity of this claim. We offer the colonoscopy suite as a potential venue to achieve baby boomer screening for chronic hepatitis.

Appendix

Risk Factor Assessment Patient Questionnaire

1. Do you already have a diagnosis of chronic Hepatitis B or C?

   • Yes

   • No

   • Unsure____________

2. Have you ever received vaccinations for Hepatitis A or B?

   • Yes- I have received and completed both

   • Yes- I started and may have fi nished one or both

   • No

   • Unsure______________

3. Have you ever had acute viral hepatitis (yellow jaundice)?

   • Yes

   • No

   • Unsure

4. 4) Were you born outside the continental United States?

   • Yes- where_________________

   • No

5. 5) Are you interested in testing to see if you would benefit from receiving Hepatitis A vaccination? (The type of hepatitis you can get from food poisoning.)

   • Yes

   • No

   • Unsure, need more information

6. 6) Are you interested in testing to see if you would benefit from receiving Hepatitis B vaccination? (The type of hepatitis you can get from blood or body fluids.)

   • Yes

   • No

   • Unsure, need more information

7. Do you wish to be tested for hepatitis B?

   • Yes

   • No

   • Unsure, need more information

8. Do you wish to be tested for hepatitis C?

   • Yes

   • No

   • Unsure, need more information

9. Do you have any of the following risk factors for chronic hepatitis B or C?

   • Yes- can specify if you wish____

   • No

     1. Ever injected or snort a drug, even once when you were young

     2. Have HIV

     3. Have hemophilia and received clotting factors before 1987

     4. Received a blood transfusion before 1992

     5. Received an organ transplant before 1992

     6. Have sexually transmitted diseases or greater than sexual partners in your life or other high risk sexual behavior

     7. Are a health care worker who has been stuck with a needle

     8. Have ever received dialysis

     9. Have a sexual partner with Hepatitis B or C

     10. Ever been in jail more than 2 days?

     11. Do you have a tattoo which was placed before 2000?

     12. Have another risk factor which you believe puts you at risk for chronic hepatitis B or C?

     13. Have no risk factors, but want to be screened for chronic hepatitis B or C

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