70% of Baby Boomers Did not Know They Had Increased Risk for HCV; 48% Did Not Know HCV is Curable
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from Jules: clearly that is why its estimated 75% in the USA who have Hcv remain undiagnosed, only perhaps 300,000 have been treated. I estimate as many as 8-9 million have HCV in the USA although the CDC estimates 2.5 million & others estimate 5 million, because none of these estimates include immigrant populations who come from countries where Hcv is very prevalent like India, Pakistan, sections of Africa, Thailand, Southeast asia, China, japan.
Misperceptions About HCV - Survey / Baby boomer HCV screening in ED at Bellevue/NYU-NYC. Almost half the patients were born outside the United States, but the majority of those foreign-born participants had lived in the US for >26 years. The majority of patient participants did not complete tertiary education and were educated to the level of a high school diploma or lower. Only 30 (37%) of patient participants were currently employed.
Baby boomers often unaware they need hepatitis C screening
- 70% DID NOT know being born between 1945-1965 increased risk for having HCV, only 29% knew Baby Boomers were at increased risk
"Baby boomers are five times more likely to have hepatitis C than those groups born before or after this period," said senior study author Dr. Ellie Carmody, an infectious disease researcher at New York University School of Medicine.
Testing is the only way to detect hepatitis C in many people who have the virus but don't feel sick, said Dr. Alexander Millman, a medical epidemiologist in the CDC's Division of Viral Hepatitis.
- 48% did not know HCV is curable or thought it was not true [27%]
- 22% did NOT know there are new more tolerable HCV medications
35% did not know HCV can lead to liver cancer & 5% thought it was not true.
38% thought it was NOT true that one could have HCV 7 look & feel fine.
11% thought you could get HCV by shaking hands with someone HCV+
9% did not know you could get HCV by IDU/sharing needles even once
56% thought there is a vaccine to prevent HCV
Knowledge about Hepatitis C Virus Infection and Acceptability of Testing in the 1945–1965 Birth Cohort (Baby Boomers) Presenting to a Large Urban Emergency Department: A Pilot Study
Journal of Emergency Medicine Feb 2016
Waridibo E. Allison, MBBS, PHD,* William Chiang, MD, Ada Rubin, BA, Lillian Oshva, MD, and Ellie Carmody, MD*
*Division of Infectious Diseases an
d Immunology, Department of Medicine, New York University School of Medicine, New York, New York and
Ronald O. Perelman Department of Emergency Medicine, New York University School of Medicine, New York, New York
Corresponding Address: Waridibo E. Allison, MBBS, PHD, Division of Infectious Diseases and Immunology, Department of Medicine, NYU School
of Medicine, 462 First Avenue, New York, NY 10016
Hepatitis C virus (HCV) is responsible for the most common chronic bloodborne infection in the United States. The Centers for Disease Control (CDC) recently recommended screening all patients born between 1945–1965 (baby boomers) at least once for HCV infection. New York State has since mandated screening of baby boomers for HCV in nearly all patient care settings and encouraged it in the emergency department (ED).
This pilot study aimed to ascertain acceptability of an HCV screening test among the 1945–1965 birth cohort presenting to the ED in advance of a study investigating the prevalence of HCV infection in this birth cohort in the ED setting.
We conducted a cross-sectional study of health knowledge about HCV and government recommendations regarding HCV testing using a convenience sample of baby boomers in an ED in a large public hospital in the New York metropolitan area. Surveys were administered via a series of semistructured interviews.
There were 81 patient participants. Fifty-two percent of patients were born outside of the United States, 69% had a high school diploma level of education or lower, and 37% were unemployed.
Patients demonstrated misconceptions about HCV transmission and curability and poor knowledge about the necessity of testing in their age cohort. Knowledge that "HCV can cause the liver to stop working" was significantly associated with acceptance of testing.
Answering "true" to the statement "Hepatitis C can cause the liver to stop working" was significantly associated with agreeing to have an HCV test if it was offered in the ED
Baby boomers showed limited knowledge about the necessity of HCV screening in their age group, but testing for HCV infection in the ED was acceptable for the majority.
⋅ 1. Why is this topic important?
⋅ The 1945–1965 birth cohort (baby boomers) has been identified as being at higher risk of hepatitis C virus (HCV) infection compared to the general population. The US Centers for Disease Control and Prevention recommends that this birth cohort should be screened at least once for HCV infection. Effective new treatments for HCV infection are now available; it is important to explore all opportunities within health care settings to screen baby boomers for this infectious disease, including in the emergency department (ED).
⋅ 2. What does this study attempt to show?
⋅ We wanted to find out if baby boomers find offers of HCV testing in the ED environment acceptable and the extent of their knowledge about HCV infection and their risk for having this infectious disease.
⋅ 3. What are the key findings?
⋅ Baby boomers find screening for HCV in the ED acceptable, but their knowledge about HCV infection, including their risk of HCV infection, is limited.
⋅ 4. How is patient care impacted?
⋅ Patient presentations to the ED represent an opportunity to screen baby boomers for HCV infection. Baby boomers found to have HCV infection can be linked to care and effective antiviral treatment.
Hepatitis C virus (HCV) is responsible for the most common chronic bloodborne infection in the United States, with an estimated 3.2 million individuals chronically infected (1). The natural history of HCV infection after exposure is that 15–40% of those exposed will clear the virus spontaneously (resolution of infection) and 60–85% will develop persistent (chronic) infection; of those chronically infected, 20–30% will develop cirrhosis over the next 20–30 years if left untreated (2).
The public health implications of HCV infection have received increasing attention in recent years (3, 4). A prediction model of disease progression and mortality among Americans with prevalent HCV infection in 2005 predicted a peak between the years 2030–2035 of 38,600 cases of end-stage liver disease, 3200 referrals for liver transplant, and 36,000 deaths (4). This study concluded that low rates of HCV screening and treatment will likely significantly increase future morbidity and mortality from HCV infection without public health interventions to increase screening and treatment rates.
Direct-acting antivirals (DAAs) have revolutionized the treatment landscape for HCV, making cure a realistic goal for a large number of patients with chronic HCV infection (5). To effectively target populations that would achieve the greatest benefit from screening, various birth cohorts were analyzed by the United States (US) Centers for Disease Control and Prevention (CDC). The 1945–1965 birth cohort, also known as "baby boomers," was targeted based on numerous factors, including high overall HCV prevalence, the highest prevalence of HCV infection in the non-Hispanic black population and a lower number needed to screen to prevent one HCV-related death (6). The prevalence of HCV infection in the baby boomer birth cohort is estimated to be 3.3%. This represents more than three-quarters (77%) of all adult infections. Moreover, 60% of those infected with HCV in this age group are unaware of their status. It has been predicted that targeted screening within this population could identify more than 800,000 new cases and avoid 120,000 deaths (6).
In August 2012, the CDC recommended one-time screening for HCV infection for all individuals born between 1945 and 1965. In June 2013, the US Preventative Services Task Force supported the CDC recommendation, giving it a grade B recommendation (i.e., high certainty that the net benefit is moderate or moderate certainty that the net benefit is moderate to substantial). On January 1, 2014, a new law became effective in New York State mandating screening of baby boomers for HCV in all patients receiving inpatient and primary care services at hospitals and all patients receiving primary care services from physicians, physician assistants, and nurse practitioners regardless of setting. A notable exception to this law was the emergency department (ED), where screening of baby boomers is encouraged but not mandated (7).
Limited data exist on screening uptake and outcome for HCV in the ED. For example, Capron et al. describe screening results from an Emergency Health Unit Hospital in Picardy, France, where the local prevalence was 1.1% (8). Patients with a reported risk factor received testing, but risk factors did not include being born between 1945 and 1965. Screening uptake was not reported, and the prevalence was 2.4% among those tested (11/451). A more recent study reports HCV screening specifically among the baby boomer population in an ED in Alabama (9). Of 2323 baby boomers offered testing, 88% accepted testing, and the prevalence of HCV antibody positivity in the 1529 patients tested was 170 (11%). One hundred fifty patients had RNA polymerase chain reaction testing, and chronic HCV infection was confirmed in 102 patients (68%).
This study aimed to ascertain the level of knowledge about HCV infection and acceptability of testing for HCV infection among baby boomers presenting to a large urban, public ED >12 months after the initial CDC recommendation and within the first year of a New York State law encouraging screening in baby boomers in the ED while mandating it in other clinical settings.
This was a cross-sectional study using a convenience sample of baby boomers in an ED in a single large public hospital with academic affiliation in the New York metropolitan area. The surveys were administered through semistructured interviews that occurred between September 15, 2014 and November 8, 2014. The institutional review boards of Bellevue Hospital Center and the affiliated New York University (NYU) Langone Medical Center approved the study. Participation was anonymous, and a waiver of documentation of consent was obtained. All subjects underwent verbal consent and were provided with a study information sheet and a CDC information sheet on HCV testing in baby boomers.
Eligible participants consisted of patients born between 1945–1965 presenting to the Bellevue Hospital Center ED. Exclusion criteria for participation were: (1) refusal of an individual to participate when approached; (2) an individual triaged as triage category 1 or 2, who by definition had a life-threatening emergency that precluded study involvement in the absence of patient duress; (3) inability of an individual to successfully negotiate use of a telephone interpreter (for example, a patient with hearing difficulties); (4) an individual with a presenting complaint that could be categorized as a mental health problem; and (5) an individual who verbally stated that they are HCV-positive when approached by the researcher.
A researcher-administered questionnaire was used to collect information from baby boomers and health care providers via a semistructured interview. Prospective patient participants were identified by the ED electronic medical record system whiteboard (a list of all patients in the ED at a particular time). On an interview day, which was defined as any time between 8 am and 12 am seven days per week, participants that fulfilled the inclusion criteria were selected for approach by the researcher in order of duration of stay in the ED. Potential participants were approached by consecutively selecting individuals in order of longest duration of stay first. If necessary, a phone interpreter was used for participation. Phone interpreters were used if there was a language barrier or patient preference. Family members or friends were not used as interpreters. Data were collected on paper forms and transferred to a Research Electronic Data Capture (REDCap) database hosted by New York University (10). REDCap is a secure, web-based application designed to support data capture for research studies.
The patient questionnaire was developed based on the knowledge of HCV portion of the Hepatitis C Follow-up Survey carried out during the National Health and Nutrition Examination Survey (NHANES) from 2001–2008 (11). An expert panel consisting of two infectious disease physicians and two emergency physicians assessed the interview script for content relevance, language, and structure. The patient interview script (Appendix) consisted of three sections: sociodemographic factors, knowledge of HCV, and acceptability of testing. Hepatitis C knowledge was ascertained via either a "true or false" or "yes/no/don't know" response to a series of statements about HCV transmission and health effects. One question about hepatitis C cure was on a five-point Likert scale (from 1 = never to 5 = always). All interview questions were closed excepting one open-ended question asking participants for their reason for a "no" response to a question about whether they would accept an HCV test if it were offered to them.
Data were analyzed using SPSS statistical software (version 17; IBM, Armonk, NY) (12). Standard descriptive statistics were used to summarize response data. The significance of comparisons between groups was assessed using a chi-squared test or Fisher's exact test for small proportions at a significance level of p ≤ 0.05. Odds ratios (ORs) and 95% confidence intervals (CIs) were used as measures of association. To facilitate the interpretation of Likert-scaled responses, scaled responses were collapsed into 3 categories: disagree (scale 1 and 2) neutral (scale 3), and agree (scale 4 and 5). Open responses were analyzed qualitatively, identifying key concepts emerging from the wording of the responses and condensing these into distinct themes.
There is no consensus on how to determine the sample size for a pilot study, and different methods can be used. We used the approach of a pilot study sample size of 10% of the estimated final study size (13). A final study size was estimated as follows: assuming an approximate prevalence of HCV of 10% among a population size of 44,000 unique baby boomers presenting to the Bellevue Hospital Center ED each year, a sample size of 381 was calculated to assure that the empiric estimate was within 3% of the true prevalence (true prevalence being between 7–13% at a 95% CI). At 10% of the final study size, a minimum pilot study sample size of 38 was required.
Of the 146 patients born who were approached and who were born between 1945–1965, 81 patients agreed to the interview. This was just over double the minimum sample size calculated for this pilot study. Patient participant characteristics are summarized in Table 1. A third of patients had a primary language other than English but an interpreter was only required for 9 (11%) of patient participants. Almost half the patients were born outside the United States, but the majority of those foreign-born participants had lived in the US for >26 years. The majority of patient participants did not complete tertiary education and were educated to the level of a high school diploma or lower. Only 30 (37%) of patient participants were currently employed.
Patient responses to knowledge questions about HCV in baby boomers are shown in Table 2. Most understood the bloodborne risk factors for HCV transmission, but there were some misconceptions about transmission through kissing. However, only 24 (29%) identified that people born between 1945–1965 are more likely to have HCV infection than other age groups. The Likert-scaled response to the question "How often do treatments available today cure hepatitis C?" was answered correctly with "most of the time" by 21 (26%) of patients, and the same proportion of patients responded with "sometimes"; 14 (17%) responded with "never" and the same number of patients 9 (11%) responded with "almost never" and "always."
Answering "true" to the statement "Hepatitis C can cause the liver to stop working" was significantly associated with agreeing to have an HCV test if it was offered in the ED (p = 0.041; OR, 3.35 [95% CI, 1.04–10.8]).
Fifty-one patients or nearly two-thirds of baby boomers interviewed (63%) found HCV testing in the ED acceptable and would agree to being tested for HCV in the ED. Reasons for patient refusal to accept testing were conviction that they were not infected with HCV, being in a hurry to leave the ED, fear of needles and not wanting to have extra blood tests done, not feeling well enough, and wanting to focus on their presenting medical condition. Not feeling well enough or wanting to deal with their presenting medical conditions first were the most common reasons for refusal.