Dr Su Wang, New Jersey, USA
Working with peers to develop Innovative ways to screen people at risk of viral hepatitis in Emergency Departments
Liver cancer incidence and mortality rates are on the rise in the US, with chronic hepatitis C and hepatitis B infections being the leading causes. The majority of people infected with hepatitis B and hepatitis C are unaware of their diagnosis, even though hepatitis C is now curable with oral medication in 8-12 weeks, and hepatitis B is preventable with vaccination and treatable with medication. Scaling-up hepatitis screening is of high public health importance for early diagnosis and care of these patients, to reduce morbidity and mortality from cirrhosis and liver cancer.
In USA, CDC recommends hepatitis C screening for all baby boomers (people born 1945- 1965) and hepatitis B screening for people born in hepatitis B endemic countries.
Recognising that first point of care settings like Emergency Departments (ED) offer key opportunities to increase screening, Su Wang and her colleagues at Saint Barnabas Liver Center, New Jersey, USA initiated a programme to utilise the electronic health record (EHR) system and create an automated process to link “atrisk” groups with hepatitis C and hepatitis B tests.
The first step in the process was to create a multidisciplinary working group, including members from the ED, informatics, laboratory and billing departments, to create protocols and implement the process. The protocol was simple; if patients are born between 1945 to 1965, have bloodwork ordered by the provider and have not had previous hepatitis C diagnosis or testing, the protocol triggers an hepatitis C antibody (HCVAb) test. If the HCVAb result is positive, it reflexes to hepatitis C RNA (viral load) to confirm infection. Nursing staff and patients are then notified of the testing, and patients may opt out if they choose.
For hepatitis B, a Country of Birth (COB) field was created as part of registration to identify people from endemic countries. If the patient meets qualifications, a protocol triggers a hepatitis B surface antigen (HBsAg) test. EHR alerts of positive test results notify both nursing staff and a patient navigator (PN). The PN initiates contact with the patient to set up timely followup. The PN evaluates whether the patient already has a primary care physician (PCP) or specialist to provide hepatitis evaluation and provides lab results to those providers. If not, the PN can directly schedule patients to be seen at the Saint Barnabas Liver Center, where viral hepatitis evaluation and care are provided.
Over a 2-month period in 2018, 2,097 patients were hepatitis C eligible with 1,480 (71%) screened and 47 (3%) HCVAb+ and 14 (0.9%) confirmed infected by hepatitis C RNA. Five patients (36%) have been linked to care thus far. In 2016, prior to the screening programme, only 3% (314) of 11,836 hepatitis C eligible patients were tested, and 5.4% (17) were HCVAb positive with 0.3% confirmed current infection.
Of the 1,149 eligible for hepatitis B screening, 835 (73%) were screened and 14 (2%) were HBsAg+, and 2 (14%) have been linked to care, a rate still very low for both hepatitis B and hepatitis C. Before the screening, no baseline of eligible hepatitis B patients could be ascertained because country of birth was not collected, but 309 HBsAg tests were ordered in 2016 with 2 (0.7%) hepatitis B infected patients identified.
Dr Wang and her colleagues initiated hepatitis B and hepatitis C screening of highrisk patients in emergency departments to close the gap on the low diagnosis rates and to increase people being linked to care. Through multidisciplinary collaboration, she has set about change that has already had a remarkable impact on the lives of people in her community.