Background: Identifying individuals with undiagnosed HCV infection is the first step towards achieving the 2030 Hepatitis C Elimination goal set forth by The World Health Organization. U.S. ED-based HCV screening programs have identified thousands of previously undiagnosed HCV-infected individuals. Our goal was to assess the prevalence of missed opportunities by determining the prevalence of undiagnosed HCV infections in an ED with an ongoing testing facilitator for delivering HCV screening.
Methods: We employed dedicated testers who identified eligible patients for HCV testing (no prior HCV test, plus either HIV infection, and/or history of injection drug use), who were getting blood drawn as part of their ED evaluation. The prevalence of unrecognized HCV was determined using an identity-unlinked seroprevalence method in an urban ED, at the same time as an ongoing testing facilitator HCV screening program over a 22-day study period. Remnant blood specimens were tested for HCV antibody (anti-HCV) after de-identification. Prevalence ratio (PR) was used to compare the prevalence of anti-HCV between those who were offered and not offered testing, and those who accepted and declined testing.
Results: During the study period, 412 unique ED patients who had remnant blood specimens were eligible for HCV testing analysis. Among the 412 patients, 296 (72%) were approached for HCV testing. Of those approached, 162 (55%) accepted HCV testing and 134 declined. The identity-unlinked study revealed that the prevalence of undiagnosed HCV infection was as follows: overall, 3.9% (16/412); offered testing, 3.7% (11/296) versus not offered testing 4.3% (5/116) (PR: 0.86, 95% CI: 0.31-2.43, p=0.78). Among those who declined testing, HCV rates were 5.2% (7/134) versus 2.5% (4/162) for those who accepted testing (PR: 2.12, 95% CI: 0.63-7.07, p =0.23). Of all 16 HCV-infected individuals, 25% (4/16) were approached and accepted testing; 44% (7/16) declined testing, and the remaining 31% (5/16) were not approached.
Conclusion: In spite of an ongoing testing facilitator-driven HCV testing program, we discovered a high prevalence of undiagnosed HCV, representing significant missed opportunities. Our findings also suggest that determining the optimal HCV screening strategy in the ED remains an important gap. Further education of patients could also help reduce those missed opportunities.