VirA+EmiC Project: Evaluating Real-world Effectiveness and Sustainability of Integrated Routine Opportunistic Hepatitis B and C Testing in a Large Urban Emergency Department

Gaia Nebbia; Murad Ruf; Laura Hunter; Sooria Balasegaram; Terry Wong; Ranjababu Kulasegaram; Julian Surey; Zana Khan; Jack Williams; Basel Karo; Luke Snell; Barnaby Flower; Hannah Evans; Sam Douthwaite

Disclosures

J Viral Hepat. 2022;29(7):559-568. 

In This Article

Abstract and Introduction

Abstract

Innovative testing approaches and care pathways are required to meet global hepatitis B virus (HBV) and hepatitis C virus (HCV) elimination goals. Routine blood-borne virus (BBV) testing in emergency departments (EDs) in high-prevalence areas is suggested by the European Centre for Disease Prevention and Control (ECDC) but there is limited evidence for this. Universal HIV testing in our ED according to UK guidance has been operational since 2015. We conducted a real-world service evaluation of a modified electronic patient record (EPR) system to include opportunistic opt-out HBV/reflex-HCV tests for any routine blood test orders for ED attendees aged ≥16 years. Reactive laboratory results were communicated directly to specialist clinical teams. Our model for contacting patients requiring linkage to care (new diagnoses/known but disengaged) evolved from initially primarily hospital-led to collaborating with regional health and community service networks. Over 11 months, 81,088 patients attended the ED; 36,865 (45.5%) had a blood test. Overall uptake for both HBV and HCV testing was 75%. Seroprevalence was 0.9% for hepatitis B surface antigen (HBsAg) and 0.9% for HCV antigen (HCV-Ag). 79% of 140 successfully contacted HBsAg+patients required linkage to care, of which 87% engaged. 76% of 130 contactable HCV-Ag+patients required linkage, 52% engaged. Our results demonstrate effectiveness and sustainability of universal ED EPR opt-out HBV/HCV testing combined with comprehensive linkage to care pathways, allowing care provision particularly for marginalized at-risk groups with limited healthcare access. The findings support the ECDC BBV testing guidance and may inform future UK hepatitis testing guidance.

Introduction

Hepatitis B virus (HBV) and hepatitis C virus (HCV) infections are a considerable cause of morbidity and mortality worldwide and in the UK: recent Public Health England (PHE) estimates suggest that, in 2019, approximately 118,000 people in the UK were living with chronic HCV infection.[1] For HBV, no PHE estimates are available; the Polaris Observatory estimated that, in 2016, approximately 441,000 people were living with chronic HBV in the UK.[2]

There is now broad access to efficacious treatments that reduce both mortality and morbidity for both viral infections,[3,4] yet key challenges remain.[5] This is primarily because many infections remain undiagnosed: in 2018, around two-thirds of chronic HCV infections were estimated to be undiagnosed.[6] 81% of HBV infections in the UK were estimated to be undiagnosed in 2016.[2]

The 2016 World Health Organization (WHO) Global Health Sector Strategy on Viral Hepatitis prioritized the need for innovative testing strategies and efficient linkage to care pathways with the aim of eliminating viral hepatitis as a major public health threat by 2030.[5]

Routine blood-borne virus (BBV) testing in emergency departments (EDs) in high-prevalence areas is suggested by the European Centre for Disease Prevention and Control (ECDC) but with concession that evidence for its effectiveness is lacking.[7] In England, there were >24.8 million attendances at EDs in 2018–2019.[8] For often marginalized populations at high risk of BBVs, the ED is often a key healthcare access point.[9,10] Findings from pilot ED opt-out viral testing studies and recent multicentre UK ED seroprevalence surveys[11,12] suggested a consistent, high level of active undiagnosed BBV infections, much higher than at general population level.[13,14] UK guidance from the National Institute for Health and Care Excellence (NICE) recommends that, in high-prevalence areas, human immunodeficiency virus (HIV) testing is universally offered to adult ED attendees who are undergoing blood tests for another healthcare reason.[15] However, in contrast, no similar consideration exists in current UK hepatitis testing guidelines.[16]

In 2014, a 1-week opt-out ED testing campaign in nine UK EDs showed that this type of testing was feasible and effective.[17] Subsequently, pilot initiatives in London (UK),[18,19] and Dublin (Ireland)[20] have shown success using opt-out ED blood screening for HBV and HCV in identifying undiagnosed patients or those lost to follow-up and linking them to care. Previously we evaluated a 6-week pilot study in our centre, which demonstrated success of our model in a large inner-city ED serving a diverse population with high levels of social deprivation.[21] This current paper describes an extension of the model to evaluate its real-world sustainability. In particular, we discuss the challenges that were faced when integrating sustainable effective linkage to care into clinical routine, and methods that we employed to overcome these challenges.

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