UK emergency department screening for viral hepatitis feasible and acceptable

Keith Alcorn
Published:
04 May 2022
Andrius Kaziliunas/Shutterstock.com

Emergency department opt-out screening for viral hepatitis and linkage to care is feasible and resulted in high uptake of testing, researchers from a major London hospital report in the Journal of Viral Hepatitis.

But the study also found that linkage to hepatitis C care among previously undiagnosed people was challenging and required a high level of involvement from social services and peer workers to locate people and ensure they remained engaged in care.

Elimination of hepatitis B and hepatitis C depends on screening people at higher risk of infection, diagnosis and linkage to specialist care. But recent estimates suggest that two-thirds of hepatitis C infections and 81% of hepatitis B infections remain undiagnosed in the United Kingdom.

Risk-based screening for viral hepatitis in general practice and drugs services each contribute to identifying previously undiagnosed infections. Screening in emergency departments has been recommended by the European Centre for Disease Prevention and Control, although evidence on its effectiveness and feasibility has been lacking.

In England, several studies have shown a higher prevalence of viral hepatitis among users of emergency department services than in the general population. In areas of high HIV prevalence in England, universal testing for HIV in emergency departments is already recommended but advice on testing for viral hepatitis is lacking.

To investigate the effectiveness and sustainability of testing for viral hepatitis in an emergency department, a cross-departmental research group at Guy’s and St Thomas’ NHS Foundation Trust carried out a study of universal opt-out testing for viral hepatitis and linkage to care in the emergency department at St Thomas’ Hospital, which serves inner south London.

The electronic patient record system automatically ordered testing for hepatitis B and C for every patient admitted if they needed other blood tests, with the option to opt out of testing. Patients were provided with printed information about viral hepatitis and its treatment in multiple languages and informed at the time of blood draw of their right to opt out of testing for viral hepatitis.

Linkage to care was carried out by the care co-ordinator rather than Emergency department physicians, removing a barrier to buy-in from Emergency department physicians.

Hepatitis C testing was carried out as reflex testing, so the same sample was tested for HCV antibody and HCV antigen. This procedure means that people who test antibody positive do not have to be recalled for confirmatory testing.

During the eleven-month service evaluation, 81,088 people attended the emergency department and 36,865 received a blood test (45%). Of these, 75% accepted hepatitis B testing and 75% accepted hepatitis C testing.

A total of 235 people (0.9%) had a positive test for hepatitis B surface antigen, 523 (1.9%) had a positive hepatitis C antibody test result and 261 (0.9%) had a positive hepatitis C antigen result. There was no difference in testing uptake for either hepatitis B or C by age, gender or ethnicity.

Hepatitis B positivity was more common in men (prevalence ratio (PR) 1.5), in those aged 30-49 (PR 3.4) compared to other age groups and in other ethnicities compared to White British (PR > 6.6).

Of those diagnosed with hepatitis B, 15% were already engaged in care or had an end-of-life diagnosis unrelated to hepatitis B. Of the remaining 199 patients, 140 (70%) received their hepatitis B diagnosis. Just under half (48%) were already aware of their hepatitis B status and half of these (53%) were not engaged in care.

A total of 110 patients required linkage to care; 87% were successfully linked to care and of those linked to local services within the NHS Trust, 46 out of 86 (53%) had attended more than one clinic visit by the time of data review.

In 261 people who tested positive for hepatitis C antigen, prevalence was higher among men (PR 2.5), people who were homeless (PR 16.6) and people who were HIV positive (PR 2.8). People aged 30-49 and 50-69 were significantly more likely to test positive compared to younger people (PR 3.6). Prevalence was significantly lower in other ethnic groups compared to White British people.

Linkage to care for hepatitis C proved more challenging than for hepatitis B. Approximately half (52%) of people who tested positive for hepatitis C antigen could be contacted, although 12 died shortly after being contacted and 19 were already engaged in care. Of the remaining 99, 56 accepted linkage to care. Of those who attended appointments in the local NHS Trust, 26 of 34 had been successfully treated for hepatitis C by the time the data review was completed.

Ninety-seven people diagnosed with hepatitis C were homeless. Thirty-one of 87 homeless patients who could not be contacted by the hospital were traced by the NHS Find and Treat team, of whom 19 were subsequently approved for treatment or started treatment.

Barriers to linkage included the lack of an active mobile phone number and lack of GP registration. The service evaluation found that liaison with local homeless teams and peer support workers with experience of homelessness was essential to locate and engage homeless people in care and maintain their engagement in treatment.

The study authors say that emergency department opt-out testing is more likely to be successful in urban settings with good co-ordination between the Emergency department, clinical treatment and community teams, including social services.

Reference

Nebbia G et al. VirA+EmiC project: evaluating real-world effectiveness and sustainability of integrated routine opportunistic hepatitis B and C testing in a large urban emergency department. Journal of Viral Hepatitis, published online,31 March 2022.

DOI: https://doi.org/10.1111/jvh.13676