Testing Everyone for Hepatitis C in the ER: What Four Urban Hospitals Found

Finding people with hepatitis C virus (HCV) infection has become urgent: HCV-related illness and death have been rising, many infected people don't know it, and curative treatments now exist. Since 2012, CDC had recommended testing everyone born from 1945 to 1965 — the baby boomers. But the opioid epidemic, driven since 2013 by injected heroin and fentanyl, has fueled new HCV infections among younger people who inject drugs, and they are hard to reach with targeted testing.

The experiment

In 2015–2016, emergency departments at four urban academic hospitals adopted opt-out, universal HCV screening: every adult patient unaware of their status was offered an antibody test, and could decline.

• University of Alabama at Birmingham
• Highland Hospital, Oakland, California
• Johns Hopkins Hospital, Baltimore
• Boston University Medical Center

Each site tracked results over four months (three at Johns Hopkins), tested antibody-positive samples for HCV RNA, and used dedicated coordinators to deliver results and link patients to care.

What they found

14,252 patients were tested, and 9.2% — about one in 11 — had antibodies to HCV. 5.7% had HCV RNA, a sign of current infection, compared with an estimated 0.95% of the whole U.S. population; in each state, emergency department rates were three to five times the highest estimates for that state.

Nearly half (47.5%) of positive results were in people born after 1965 — people a baby-boomer-only strategy would have missed, even though three-quarters of U.S. infections are in the older group. The high rate among younger white patients fits the known patterns of HCV and injection drug use, though the study couldn't confirm individual risk behaviors.

Insurance mattered too. In both age groups, rates were higher among patients with Medicaid or other public insurance, Medicare, or other or unknown insurance than among the commercially insured — for example, 17.7% compared with 8.4% in the older group.

Why universal testing

• It finds more infections, especially among younger adults.
• It reduces stigma, because testing doesn't depend on asking patients about risky behavior — a lesson from HIV testing.
• It's easier to run in busy emergency departments than screening that requires risk questions.
• It can help fight the linked epidemics of opioid overdose and bloodborne infections, through harm reduction and navigation to treatment.

Its approach matched a newer recommendation: test all adults at least once in their lifetime, except where fewer than 0.1% test positive.

Barriers

• A 2014 decision by the Department of Health and Human Services and the Centers for Medicare & Medicaid Services barred emergency departments from reimbursement for hepatitis C testing, which may limit adoption.
• Finding so many infections strains navigation programs, which need strong support to connect people to HCV treatment, primary care, social services and substance use treatment.

Limitations

• "Previously unrecognized" infection depended on patients' recall of past diagnoses.
• 29,255 eligible patients weren't tested — because no blood was drawn for other tests, an earlier result was on file, or they declined.
• Results come from four urban academic hospitals and may not apply to rural or community emergency departments.

Sources

Based on Galbraith JW, Anderson ES, Hsieh YH, et al., "High Prevalence of Hepatitis C Infection Among Adult Patients at Four Urban Emergency Departments — Birmingham, Oakland, Baltimore, and Boston, 2015–2017," Morbidity and Mortality Weekly Report 69(19), Centers for Disease Control and Prevention; a work of the United States government in the public domain. Original report.