An innovative approach to increase viral hepatitis diagnoses and linkage to care using opt-out testing and an integrated care pathway in a London Emergency Department

Abstract

Therapies that halt progression of chronic hepatitis B virus (HBV) and achieve a cure for chronic hepatitis C virus (HCV) have encouraged development of innovative strategies to diagnose and link patients to care. We describe the prevalence and risk factors for HBV and HCV infections and use of an opt-out hepatitis testing and integrated linkage to care pathway in a London Emergency Department (ED). ED patients aged ≥16 years having routine blood tests from 15 February-28 March 2016 were tested for hepatitis, unless opted out. Hepatitis B surface antigen (HBsAg) and hepatitis C antibody tests (HCV-Ab, including a confirmatory hepatitis C antigen test (HCV-Ag)) were pre-selected on electronic blood test requests. Linkage to care (attending one clinic appointment) was offered to HBsAg and HCV-Ag patients (new or known-disengaged with care diagnoses). Weighted prevalence estimates and risk factors for seropositivity adjusted by demographics and survey weights were calculated using logistic regression. Hepatitis testing uptake was 56% (3,290/5,865). Overall, 26 HBsAg (10 new diagnoses) and 63 HCV-Ab patients were identified of which 32 were HCV-Ag positive (10 new diagnoses). Weighted seroprevalence of HBsAg was 0.50% (95% CI 0.3–0.8%); HCV-Ab 2.0% (95% CI 1.5–2.7%) and HCV-Ag 1.2% (95% CI 0.8–1.7%). Risk factors for infection were being male (HBsAg: aOR 4.1, 95% CI 1.5–11.3), of non-White British ethnicity (HBsAg: aOR>11) or being homeless (HCV-Ag: aOR 18.9, 95% CI 6.9–51.4). We achieved a high linkage to care uptake for HBsAg (93%) and HCV-Ag (78%) among patients who were contacted and required linkage. A pre-selected hepatitis testing ordering system facilitated a high testing uptake. New and disengaged with care diagnoses and a high HCV prevalence were identified demonstrating the potential to identify and link patients to care in this setting. Strategies connecting clinical care with community outreach services are key for improving patient linkage to care.