Hepatitis C Screening Beyond CDC Guidelines
Hepatitis C Screening Beyond CDC Guidelines
Persons of Egyptian origin living in our targeted community had the highest HCV Ab prevalence compared to all other nationals. To our knowledge, HONE is the first group that has successfully performed targeted community-based screening for HCV in Egyptian persons living in the USA. This programme has successfully linked newly diagnosed Egyptian patients to medical care and treatment where appropriate.
The prevalence of HCV Ab in our study of Egyptian persons residing in the USA was 15.6% and is similar to the estimated prevalence of HCV infection in persons residing in Egypt (14.7%) based on data from the Egyptian national health survey. The prevalence of HCV infection in our cohort of Egyptian persons also increased with age and parallels findings reported in Egypt. Additionally, rates of HCV infection in Egypt are reportedly higher in persons residing in rural areas, similar to the findings in this study.
According to the CDC, at least 10% of persons with chronic HCV infection do not fall within the current high-risk groups to target for screening. The National Health and Nutrition Examination Survey III data suggest that HCV prevalence is highest among US residents born from 1945 to 1965 (Baby Boomer Birth Cohort). To identify more cases of HCV-infected persons, the CDC recently added Baby Boomer Birth Cohort to the list of groups at high-risk for HCV infection. There are countries outside the USA that have a higher prevalence of HCV infection, yet screening for HCV in foreign-born communities is currently not pursued. The IOM report states that screening of Egyptian immigrants to the USA should be considered. HONE data presented here and elsewhere support a recommendation to consider screening in persons born in Egypt and also support targeted screening in persons born in countries with HCV prevalence of >2%. If these recommendations are to be adopted in future, methods to avoid stigma and discrimination would be strongly recommended for study and implementation.
We found a strong association of years in residence in Egypt and HCV infection. This suggests that residence in Egypt is an exposure factor. Reasons for this are not clear, but likely related to iatrogenic modes of transmission. Worldwide, there is substantial preventable burden of HCV because of iatrogenic transmission. There is a high prevalence of transfusions, reuse of needles and syringes, needle-stick injuries among healthcare workers and unnecessary medication injections. It has been estimated that approximately 2 million HCV infections are acquired annually from contaminated healthcare injections, and may account for up to 40% of all HCV infections worldwide. In addition to unsafe injection practices, in some countries, poor or non-existent infection control in health and dental care facilities may be a source of HCV transmission. In Egypt, where the prevalence of HCV is the highest in the world, the reuse of glass syringes during the parenteral therapy campaigns to control endemic schistosomiasis is a widely held hypothesis of iatrogenic transmission. There may have been considerable other concurrent iatrogenic exposures at the time. More recent evidence in Egypt supports a continuation of iatrogenic exposures that is contributing to ongoing HCV transmission.
A high percentage of infected Egyptian persons received a full medical evaluation in the HONE programme. In select populations, follow-up rates for HCV-infected persons have been reported to be 20% or less. Culturally targeted telephone-based PNs can provide a vital link between patients and medical providers by acting as a point of contact, providing important health education to address disease and health beliefs and providing psychosocial support. Freeman and colleagues originally suggested patient navigation as a method to improve access to medical services for low-income minority patients.
The HONE programme continues to be refined. While 60% of persons who were HCV Ab positive attending a follow-up visit, 40% did not access follow-up care. More data are needed on barriers and facilitators for accessing screening and follow-up care and currently a qualitative study is underway to help answer identify and understand these factors. Additionally, HONE is seeking better tracking methods to follow all persons diagnosed with infection.
The implications of these findings extend beyond the screening and treatment of high-risk patients in a single ethnic population in New York. Rather, they help establish a broader novel paradigm for targeted community-based viral hepatitis screening, detection and treatment that could resonate among dozens of ethnic communities throughout the USA, affecting many at-risk individuals. Through partnership of an academic medical institution, CBOs, federally qualified health centres and the local city departments of health, the HONE programme has potential for replication in other communities outside New York City.
The HONE was successful at recruiting foreign-born Egyptian persons to screening events, diagnosing new cases of HCV infection and linking persons with infection to care. The success of community partnerships, use of language of origin in recruiting foreign-born persons to screening events, the use of non-traditional venues for education and screening and the use of culturally targeted PNs to provide extra assistance may improve the success rate in other places with similar communities.
Discussion
Persons of Egyptian origin living in our targeted community had the highest HCV Ab prevalence compared to all other nationals. To our knowledge, HONE is the first group that has successfully performed targeted community-based screening for HCV in Egyptian persons living in the USA. This programme has successfully linked newly diagnosed Egyptian patients to medical care and treatment where appropriate.
The prevalence of HCV Ab in our study of Egyptian persons residing in the USA was 15.6% and is similar to the estimated prevalence of HCV infection in persons residing in Egypt (14.7%) based on data from the Egyptian national health survey. The prevalence of HCV infection in our cohort of Egyptian persons also increased with age and parallels findings reported in Egypt. Additionally, rates of HCV infection in Egypt are reportedly higher in persons residing in rural areas, similar to the findings in this study.
According to the CDC, at least 10% of persons with chronic HCV infection do not fall within the current high-risk groups to target for screening. The National Health and Nutrition Examination Survey III data suggest that HCV prevalence is highest among US residents born from 1945 to 1965 (Baby Boomer Birth Cohort). To identify more cases of HCV-infected persons, the CDC recently added Baby Boomer Birth Cohort to the list of groups at high-risk for HCV infection. There are countries outside the USA that have a higher prevalence of HCV infection, yet screening for HCV in foreign-born communities is currently not pursued. The IOM report states that screening of Egyptian immigrants to the USA should be considered. HONE data presented here and elsewhere support a recommendation to consider screening in persons born in Egypt and also support targeted screening in persons born in countries with HCV prevalence of >2%. If these recommendations are to be adopted in future, methods to avoid stigma and discrimination would be strongly recommended for study and implementation.
We found a strong association of years in residence in Egypt and HCV infection. This suggests that residence in Egypt is an exposure factor. Reasons for this are not clear, but likely related to iatrogenic modes of transmission. Worldwide, there is substantial preventable burden of HCV because of iatrogenic transmission. There is a high prevalence of transfusions, reuse of needles and syringes, needle-stick injuries among healthcare workers and unnecessary medication injections. It has been estimated that approximately 2 million HCV infections are acquired annually from contaminated healthcare injections, and may account for up to 40% of all HCV infections worldwide. In addition to unsafe injection practices, in some countries, poor or non-existent infection control in health and dental care facilities may be a source of HCV transmission. In Egypt, where the prevalence of HCV is the highest in the world, the reuse of glass syringes during the parenteral therapy campaigns to control endemic schistosomiasis is a widely held hypothesis of iatrogenic transmission. There may have been considerable other concurrent iatrogenic exposures at the time. More recent evidence in Egypt supports a continuation of iatrogenic exposures that is contributing to ongoing HCV transmission.
A high percentage of infected Egyptian persons received a full medical evaluation in the HONE programme. In select populations, follow-up rates for HCV-infected persons have been reported to be 20% or less. Culturally targeted telephone-based PNs can provide a vital link between patients and medical providers by acting as a point of contact, providing important health education to address disease and health beliefs and providing psychosocial support. Freeman and colleagues originally suggested patient navigation as a method to improve access to medical services for low-income minority patients.
The HONE programme continues to be refined. While 60% of persons who were HCV Ab positive attending a follow-up visit, 40% did not access follow-up care. More data are needed on barriers and facilitators for accessing screening and follow-up care and currently a qualitative study is underway to help answer identify and understand these factors. Additionally, HONE is seeking better tracking methods to follow all persons diagnosed with infection.
The implications of these findings extend beyond the screening and treatment of high-risk patients in a single ethnic population in New York. Rather, they help establish a broader novel paradigm for targeted community-based viral hepatitis screening, detection and treatment that could resonate among dozens of ethnic communities throughout the USA, affecting many at-risk individuals. Through partnership of an academic medical institution, CBOs, federally qualified health centres and the local city departments of health, the HONE programme has potential for replication in other communities outside New York City.
The HONE was successful at recruiting foreign-born Egyptian persons to screening events, diagnosing new cases of HCV infection and linking persons with infection to care. The success of community partnerships, use of language of origin in recruiting foreign-born persons to screening events, the use of non-traditional venues for education and screening and the use of culturally targeted PNs to provide extra assistance may improve the success rate in other places with similar communities.
Source...