Positive Hepatitis C Virus Antibody Research Articles

309. Should Primary Care Practitioners Follow Hepatitis C Exposed Infants?

BackgroundHepatits C virus (HCV) infection in pregnancy is estimated between 1–4% and risk of vertical transmission ~5%. While the benefits of HCV testing for perinatally exposed infants under a year is debatable, a strategy for follow-up (F/U) is important. We instituted interventions to improve the F/U rate for HCV exposed infants in December 2012. Pediatric infectious diseases (PID) service was consulted in the newborn period to establish care. Perinatal HCV exposure was added to the infant’s electronic record. Educational brochures were given to guardians at discharge. We aimed to assess the efficacy of the interventions in improving the F/U rate.MethodsA retrospective chart review of 227 HCV exposed infants born between January 2013 and December 2016 was done after obtaining IRB. Infant charts were reviewed for maternal age, race, insurance, HCV risk factors, HIV and Hep B co-infection, third trimester HCV PCR, delivery type, gestational age, birth weight and infant custody. Based on 2002 NIH guidelines: first visit at 6–8 weeks, second at 6–8 months, final visit ≥18 months of age. Maternal HCV infection is positive HCV antibody (Ab) during pregnancy, medical care defined as at least one infant PID clinic visit, and appropriate F/U as an 18-month visit for HCV (Ab) check. Univariate analysis is used for demographics, descriptive summaries were recorded as frequencies and percentages.Results214 infants included in analysis (1 deceased and 12 adopted and left area). Baseline characteristics of those who had medical care vs. not were similar except for infant custody and HIV co-infection 94/214 (44%) had medical care. Of those, 32/94(34%) had appropriate F/U while 62/94(66%) did not 31/214 infants were followed by primary care practitioners (PCPs) at our institution. Of those 24/31(77.5%) were either tested inappropriately or lost to F/U HIV co- infection and custody by a relative (not mom) increase the likelihood of F/U (P 0.003 and 0.002, respectively) 5 infants contracted HCV infection. One infant who lost to F/U was diagnosed incidentally in the ER.ConclusionAppropriate F/U for HCV exposed infants poses challenges despite established systems of care. Because current guidelines recommend antibody testing at 18 months, educating PCPs who are more likely to establish regular F/U is important for appropriate testing.Disclosures All authors: No reported disclosures.

305. Using Big Data to Re-Engage Hepatitis C-infected Persons: A UK Operational Delivery Network’s Experience

BackgroundThe prevalence of hepatitis C (HCV) varies across different risk groups in the UK. In England, responsibility for the co-ordination and administration of DAAs (direct-acting antivirals) to HCV PCR positive patients is with 22 regional “Operational Delivery Networks” (ODNs). To attempt to eliminate Hepatitis C before 2030, Public Health England (PHE) and NHS England (NHSE) are attempting to re-engage previously diagnosed infected persons. To this end, ODNs have been supplied with historical antibody result data to target and reengage individuals for PCR testing and intervention if required.A study was designed to evaluate these data to help with informing ODN decisions. This study aimed to ensure that the data accurately identified patients that were PCR positive for HCV and thus fit the current criteria for receiving DAAs.MethodsThe regional ODN for the West Midlands was provided with 4540 patients with historical positive HCV antibody results, collected by a PHE surveillance system, to target for DAA intervention. DAA-treated patients had been excluded. Patient details were cross-referenced with all PCR results from January 1, 1996 up to January 1, 2019 at several regional laboratories (Public Health England Birmingham, the Queen Elizabeth Hospital, City and Sandwell Hospital) and national treatment data.ResultsPCR data were found for 988, 276 (28%) of whom had received treatment. Of the 712 persons untreated, 347 (49%) were PCR negative and thus would not fit the criteria for receiving DAAs. 365 (51%) had a positive PCR result without a record of treatment would be eligible for DAAs (see Figure 1).ConclusionOur study suggests approximately one-third of patients identified by cross-referencing NHSE treatment and PHE epidemiological HCV antibody databases will be PCR-positive and suitable for re-engagement. Epidemiological data needs to be accurately curated when implementing public health control measures. Using “Big Data” to target interventions has several limitations but can be useful. DAAs for HCV are not without risk and administration should be clinically justified. Re-testing individuals prior to intervention is essential and other methods of elimination, for example “test and treat,” may be more efficient and accurate. Disclosures All authors: No reported disclosures.

1292. Integrating HIV and Hepatitis C Screening in a High-Risk Emergency Department Population

BackgroundWith the acceleration of the hepatitis C (HCV) epidemic in the United States and the ongoing public health impact of undetected human immunodeficiency virus (HIV) co-infection, there is a critical need for enhanced secondary prevention efforts where patients accessing care are not routinely screened. The purpose of this program was to implement routine opt-out HIV and HCV screenings in a high-volume urban emergency department (ED) through the use of an EMR enhancement to increase a provider’s likelihood of testing eligible patients, and to provide linkage to care for patients identified to have positive tests.MethodsFrom November 27, 2018 to March 31, 2019, EMR-based HIV and HCV screening was implemented in a quaternary care ED in Northern California. EMR best practice alerts were developed based on a combination of local and CDC guidelines and populated on registered patients receiving blood laboratories or receiving STI testing. Laboratory HIV/HCV screening utilized a unique two-specimen collection scheme to enable molecular testing without requiring patient return visits. Patients were excluded if they chose to opt out from testing or the provider deemed opt out was not possible. Upon notification of a positive test result through the EMR, a patient navigator was responsible for providing disease education and linking patients to care.ResultsThe prevalence of HCV antibody positivity was 9.6% (637/6,627) and 0.97% (55/5,628) for HIV. Of the 255 HCV-RNA positives, 110 were known and 145 newly diagnosed. Of the 90 HIV patients, 31 were known and 8 newly diagnosed. Although current CDC hepatitis C screening guidelines recommend screening all adults born during 1945–1965, we conducted universal screening of adults 18 years or older. Of those screened antibody-positive for HCV 64% fell within the 1945–1965 birth cohort.ConclusionIntroducing routine opt-out testing using an automated EMR-based screening program is an effective method to identify and screen eligible patients for HIV and HCV in episodic care safety net settings where universal screenings are not routinely implemented. The unexpectedly high rate of HIV seroprevalence suggests the ED environment continues to be an important setting to access populations not receiving routine care despite longstanding CDC recommendations for universal screening. Disclosures All authors: No reported disclosures.

1084 Does Viremia in Patients With Hepatitis C Antibody Positivity Alter Mortality in People Who Inject Drugs With Infective Endocarditis?

INTRODUCTION: Injection drug use [IDU] is a well-known risk factor for both infective endocarditis [IE] and hepatitis C virus [HCV] infections. In parallel with the opioid epidemic, the incidence of both infections has increased in recent years. In this retrospective study, the impact of HCV on mortality of people who inject drugs [PWID] with IE is assessed. METHODS: Electronic medical records of adult patients diagnosed with IE according to modified Duke criteria from January 2012 through May 2018 at an academic tertiary medical center were analyzed. Patients were identified as PWID based on IDU documentation within 3 months of admission. The study included all patients with a positive HCV antibody. Patients were then stratified into two groups: “Positive HCV viremia” [positive HCV antibody and viral load] or “Negative HCV viremia” [positive HCV antibody but negative viral load]. Prior HCV treatment, HIV infection, and absence of documented HCV seropositivity precluded study enrollment. Pertinent demographic, clinical, laboratory, microbiologic, and outcome data were recorded and analyzed. RESULTS: One hundred and twenty-nine PWID with IE were identified, of whom 110 [85.2%] had a positive HCV antibody. Of these, 23 patients were excluded due to lack of testing for viral RNA. , resulting in 87 HCV study patients [67.4%]. Fifty-three [61.0%] patients had viremia and 34 [39.1%] did not. Of the 87 study patients, 85.1% were Caucasian and 52.9% were female with a median age of 25. Six [6.9%] patients had previous IE. The most commonly injected drug was prescription opioids [69.0%]. The tricuspid valve was involved in 56.3% of patients and the most common pathogen was Staphylococcus aureus [71.3%]. Prescription opioid injection, S. aureus infection, tricuspid valve involvement, and 10-week mortality did not differ between the viremic and non-viremic HCV groups [Table 1]. CONCLUSION: While several host and clinical factors affect mortality in PWID with IE, HCV viremia does not appear to increase mortality. However, larger, prospective studies will be required to better delineate the significance of HCV viremia among PWID with IE.

995 Lost to Follow-Up: Patients Diagnosed With Hepatitis C Virus During Pregnancy May Not Seek Postpartum Treatment

INTRODUCTION: Patients diagnosed with hepatitis C virus (HCV) during pregnancy represent a unique treatment challenge; direct acting antiviral agents are not currently approved for use during pregnancy. Treatment is delayed until postpartum that may lead to ‘leakage’ of patients ultimately resulting in persistent, untreated infection. We sought to determine the rate of persistent infection in patients diagnosed with HCV during pregnancy in obstetrics (OB) clinics across our health system and determine reasons for non-treatment following pregnancy. METHODS: We queried our health system’s EHR to identify patients with positive HCV antibody and/or RNA who were initially tested during prenatal testing in OB clinics between 2011–2018. We obtained demographic data, liver imaging and fibrosis scores, and determined level of postpartum engagement in health care for HCV treatment. RESULTS: A total of 110 patients were identified who were diagnosed in OB clinic during pregnancy and remained untreated. Ninety-two (84%) patients had follow-up in the first 6 months with any care provider but only 28 (25%) patients presented for follow up in GI clinic. The average time for presentation to GI clinic was 14 weeks after initial diagnosis. Of the patients assessed in GI clinic, 3 patients (11%) were prescribed therapy but did not have evidence of initiating therapy or achieving SVR. There were 12 patients (43%) who were assessed for therapy and required more testing and subsequently lost to follow up. Patients were not offered treatment in 21% (6/28) of cases due to lack of evidence for advanced fibrosis/cirrhosis at time of diagnosis. 25% of patients were evaluated in GI clinic prior to delivery (7/28) but did not present for follow up in the post postpartum period. For the entire cohort, there was no evidence of HIV or HBV co-infection. Only two patients had evidence of steatosis of liver US and no patients had evidence of advanced fibrosis (Fibrosure 0-1; low FIB-4 score). CONCLUSION: Patients diagnosed with HCV during pregnancy are at risk for ‘leakage’ from care in the postpartum period. Our study found a minority of patients presented for follow up in GI clinic for treatment and the vast majority of those patients did not receive treatment. Developing linkage to care programs to retrospectively reengage untreated patients and develop prospective protocols for close monitoring and outreach for future cases may help decrease this gap in care.

1009 The Use of a “Pop Up” Identification System Can Lead to the Identification and a High Percentage of Treatment of Patients With Chronic Hepatitis C

INTRODUCTION: The World health Assembly has set as a goal the elimination of hepatitis C (HCV) as a public health threat by 2030. In the United States, a problem with elimination of HCV is that many patients that are infected are not identified, and the majority who screen positive for HCV, for a variety of reasons, do not receive treatment. In Texas, it has been estimated that only 25% of patients identified as infected actually receive treatment. The cost of treatment has decreased significantly, and lack of coordinated care may partially account for the low treatment rates. The majority of patients with chronic HCV were born 1945-1965, and it has been recommended that patients in this birth cohort be routinely screened with hepatitis c antibody. Kelsey-Seybold Clinic is an accountable health care organization that has about 1 1/2 million patient visits a year. At least 2/3's of the patients receive essentially all their care in our system. currently, there is a pop up message in the electronic medical records of patients in the 1945-1965 cohort when they are seen by their primary care physician as a reminder to check the HCV antibody if not previously done. We wanted to determine if this coordinated system led to a higher percentage of patients being treated than historically reported. METHODS: Utilizing the appropriate codes, we examined the data base for 2018 to see 1) what number of patients in this birth cohort with a positive HCV antibody had a HCV RNA performed 2) what number were referred for treatment 3)what number received treatment. RESULTS: A total of 8902 patients in the cohort were screened, and 136 (1.5%) were positive for HCV antibody. 113 of the 136 (83.1%) had a positive HCV RNA. At this time, 97 of the 113 have been seen by gastroenterology and hepatology and 85 have so far received anti-viral therapy for a treatment rate of 75.2%. At the time of presentation, updated treatment numbers and response rates will be available. CONCLUSION: Utilizing a system of coordinated care, we have been able to identify a large number of patients in the 1945-1965 birth cohort, and subsequently treat a higher percentage of actively infected patients than has been previously noted.

Hepatitis A and Hepatitis B Vaccination Coverage Among Persons Who Inject Drugs and Have Evidence of Hepatitis C Infection.

Despite recommendations for vaccination against hepatitis A virus (HAV) and hepatitis B virus (HBV) for all adults at increased risk of infection, several US states have reported increases in HAV and HBV infections among persons who inject drugs. We investigated hepatitis A and hepatitis B vaccination coverage among a sample of persons who reported injecting drugs and had evidence of hepatitis C virus (HCV) infection. We searched the Wisconsin Immunization Registry for the vaccination records of persons who underwent HCV testing at syringe services programs from January 1 through August 31, 2018, and were reported to the Wisconsin Division of Public Health as having positive HCV antibody test results and a history of injection drug use. We calculated the percentage of persons who were vaccinated according to national recommendations. Of 215 persons reported, 204 (94.9%) had a client record in the Wisconsin Immunization Registry. Of these 204 persons, 66 (32.4%) had received ≥1 dose of hepatitis A vaccine, 46 (22.5%) had received 2 doses of hepatitis A vaccine, and 115 (56.4%) had received 3 doses of hepatitis B vaccine. Hepatitis B vaccine coverage decreased with increasing age, from 88.0% (22 of 25) among adults aged 20-24 to 30.3% (10 of 33) among adults aged 35-39. These findings suggest that most persons who inject drugs in Wisconsin are susceptible to HAV infection and that most persons aged ≥35 who inject drugs are susceptible to HBV infection. In addition to routine vaccination of children, targeted hepatitis vaccination programs should focus on adults who inject drugs to help prevent future infections.

Hepatitis C Virus Infection in the Dallas County Jail: Implications for Screening, Prevention, and Linkage to Care.

Screening for hepatitis C virus (HCV) infection in jail provides an opportunity to educate and offer care to a high-risk population. We aimed to (1) estimate the prevalence of HCV infection in jail; (2) describe the demographic characteristics, risk factors, and pre-incarceration health insurance status associated with HCV infection; and (3) examine the implementation of HCV screening in jail. We conducted a retrospective analysis of an opt-out HCV screening program with HCV RNA confirmation and patient education at the Dallas County Jail from April 1 through November 2, 2017. We extracted data on test results, demographic characteristics, and release destination from electronic medical records. A nurse navigator recorded data on patient self-reported risk factors and pre-incarceration health insurance status. Of 4089 incarcerated persons screened, 708 (17.3%) had a positive HCV antibody result. Of these, 641 (90.5%) had an HCV RNA test ordered; 576 (89.9%) had RNA tests completed, of whom 413 (71.7%) had a positive HCV RNA result. Of these 413, 352 (85.2%) received patient education. Half of HCV RNA-positive incarcerated persons (n = 207, 50.1%) were born outside the birth cohort (1945-1965). Among those with HCV infection, commonly reported risk factors were injection drug use (168 of 352; 47.8%) and tattoos (82 of 352; 23.4%). Most incarcerated persons with HCV infection (284 of 350; 81.1%) did not have health insurance. HCV antibody prevalence was higher among incarcerated persons released to prison (232 of 961; 24.1%) than to outside agencies (38 of 403; 9.4%) or the community (178 of 1026; 17.4%). Screening for HCV with RNA confirmation in jail provides an opportunity for disease education, transmission prevention, and navigation to HCV treatment. Future efforts should examine post-incarceration linkage to care.

Hepatitis C Screening in an Underserved U.S. Cohort of Reproductive Age Women.

The opioid epidemic has recently increased the rates of hepatitis C virus (HCV) infection among young women. We therefore aimed to characterize the cascade of HCV care in a cohort of underserved women of reproductive age. Medical records of 19,121 women between the ages of 15 and 44 years, receiving primary care in the San Francisco safety‐net health care system, were reviewed. Cohort characteristics were as follows: median age 33 years (interquartile range 26‐38), 18% white (12% black, 46% Latina, 22% Asian, 2% other race), 1.3% hepatitis B surface antigen (HBsAg)‐positive, and 0.9% human immunodeficiency virus (HIV) co‐infection. HCV antibody (HCVAb) testing occurred in 38.7% (n = 7,406), of whom 2.8% (n = 206) were HCVAb‐positive and 2.4% (n = 177) had a detectable HCV viral load. Of the 5% (n = 1,017) with a history of pregnancy, 61% (n = 615) had HCVAb testing (2.6% were positive). On multivariable analysis, HBsAg testing (odds ratio [OR] 8.25 [95% confidence interval (CI)] 6.80‐10.01]; P < 0.001), HIV infection (OR 5.98 [95% CI 1.86‐19.20]; P = 0.003), and log alanine aminotransferase (ALT) (OR 1.30 [95% CI 1.16‐1.45]; P < 0.001) were associated with HCV screening. Compared with whites, women of Latina (OR 0.45 [95% CI 0.37‐0.55]; P < 0.001) and Asian (OR 0.74 [95% CI 0.58‐0.94]; P = 0.01) race were less likely to receive HCV screening. Age (OR 1.80 per decade [95% CI 1.26‐2.57]; P = 0.001), white race (versus non‐white; OR 10.48 [95% CI 7.22‐15.21]; P < 0.001), HIV infection (OR 3.25 [95% CI 1.40‐7.55]; P = 0.006), and log ALT (OR 1.93 [95% CI 1.49‐2.49]; P < 0.001) were associated with HCVAb positivity. Conclusion: Most (>60%) underserved women of reproductive age were not tested for HCV. Moreover, women of Latina and Asian race were less likely to receive HCV screening. Given the known high HCV risk in the underserved population, targeted interventions, especially for racial minority women of reproductive age, are needed to enhance HCV screening in those at risk.

Achievement of hepatitis C cascade of care milestones: a population-level analysis in Alberta, Canada.

Despite highly effective directly acting antiviral (DAA) therapy for hepatitis C virus (HCV), many patients do not receive treatment. We characterized the achievement of cascade of care milestones within 2years of diagnosis among the Alberta population and evaluated variables associated with engagement at each stage. All Albertans with a first-time positive HCV antibody between 2009 and 2014 were included in this retrospective study. We determined which patients received follow-up testing (HCV RNA and HCV genotype), referral to hepatitis specialty care, and antiviral prescription, and achieved SVR within 2years of diagnosis. Factors associated with achieving cascade milestones were identified by multivariable logistic regression analysis. Of 6154 patients with HCV antibody and complete follow-up, 4238 (68.9%) had HCV RNA testing, 2360 (38.3%) had HCV genotyping, 2096 (34.1%) were assessed by a specialist, 711 (11.6%) were prescribed treatment and 207 (3.4%) achieved SVR within 2years of diagnosis. Independent variables associated with reduced likelihood of achieving cascade milestones were Indigenous heritage (adjusted odds ratio (AOR) 0.53 (0.41-0.68) for HCV RNA testing), unstable housing (AOR 0.50 (0.32-0.79) for specialist assessment) and alcohol misuse (AOR 0.61 (0.38-0.99) for antiviral prescription). Men, older patients, patients with a higher income and patients with more advanced liver disease were more likely to achieve cascade of care milestones. At each stage of patient engagement, opportunities for improvement were identified. Understanding the local cascade of care and factors associated with achieving cascade milestones will help prioritize initiatives to facilitate access to DAA therapy in Alberta.

Predictive factors for not undergoing RNA testing in patients found to have hepatitis C serology and impact of an automatic alert.

The process of diagnosis and linkage to care in cases of hepatitis C virus (HCV) infection remains an obstacle to disease control. The aims of this study were to evaluate predictive factors for not undergoing RNA testing among patients with positive HCV serology and impact of incorporating an automated electronic alert with recommendations in clinical practice. We collected HCV antibody tests requested from October 2011 to September 2014 to evaluate the rate of RNA testing and predictive factors for not undergoing RNA testing. Since October 2014, an automated alert notification has been implemented to remind physicians for testing RNA after a positive HCV test and referral to specialist care. 41403 HCV antibody tests were requested from 34073 patients. 870 (2.55%) patients tested positive. After a median of follow-up of 57.0months (range 45.6-82.1), 37.6% did not have RNA testing. The independent predictors for not undergoing RNA testing were primary care serology requests (P<0.001), no history of drug use (P=0.005) and a lack of social support (P=0.015). The intervention impact was evaluated in a pre-alert cohort (October 2011-September 2014) and a post-alert cohort (October 2014-September 2015). After the incorporation of the alert, the rate of RNA testing increased from 62.4% to 77.7% (P<0.001). Incomplete assessment of HCV infection is a challenge in primary care. The implementation of an automated alert for recommending RNA testing after a positive HCV antibody test is feasible in clinical practice and increases the rate of patients with RNA testing.

Mental health outcomes for individuals with chronic hepatitis C infection.

ObjectiveUsing data from the 2011–2015 IBM MarketScan® Commercial Claims and Encounters, we sought to assess the relationship between mental health outcomes and chronic hepatitis C infection after adjusting for important confounders. Persons with HCV antibody and RNA test results between 2011 and 2015 and continuous enrollment in fee-for-service plans were included in the analysisIntroductionHepatitis C virus (HCV) infection is a leading cause of liver disease-related morbidity and mortality in the United States and HCV incidence has been increasing. Mental illness may impact the likelihood of initial HCV infection, progress and adherence to treatment along the hepatitis C care cascade, and risk of subsequent reinfection for those cured of hepatitis C. The relationship between HCV infection and mental illness is not well understood and many studies have lacked sufficient sample size to adjust for important confounders. We sought to explore the association between chronic HCV infection and mental illness after adjusting for important confounders.MethodsWe obtained data from the 2011–2015 IBM MarketScan® Commercial Claims and Encounters and Medicare Supplemental and Coordination of Benefits databases. These data consist of inpatient and outpatient service claims for persons with employer-sponsored health insurance coverage and their dependents. Persons with HCV antibody and RNA test results between 2011 and 2015 and continuous enrollment in a fee-for-service plan were included in the analysis. Chronic HCV infection was defined by a positive HCV RNA test result. Controls without chronic HCV infection had a negative HCV antibody test result and no positive HCV antibody or RNA test result in the preceding or following year. The index date was defined by the date of the earliest positive HCV RNA or negative HCV antibody test. Demographic characteristics were obtained from the MarketScan® enrollment tables. All enrollees in the study population were at least 18 years old during the year of the index date. The analysis sample was restricted to persons who were identified as receiving outpatient prescription drug claims data feeds. We estimated adjusted odds ratios (OR) for the association between mental illness (ICD-9 code 295 or 296) and HCV RNA status. Multivariate models included age (18-44, 45-64, 65+ years), sex, region, and an adjusted Charlson Comorbidity Index which excluded liver disease and hepatocellular carcinoma.ResultsWe identified 2,847 individuals with chronic HCV infection (HCV RNA+) and 57,418 controls who were HCV antibody negative. With respect to age, 83% of HCV RNA+ individuals were aged 45-64 years while only 43% of the HCV antibody negative individuals were in the same age range. Similarly, for sex, 62% and 40% of HCV RNA+ individuals and controls, respectively, were male. For unadjusted analyses, age, sex, region, comorbid conditions, and mental illness (OR= 2.25 [95% CI; 1.52 - 3.34]) were all statistically associated with HCV RNA+. For the multivariate adjusted models, these same variables remained statistically significant. For the multivariate model, individuals with a mental illness were more likely to be HCV RNA+ relative to HCV antibody negative controls. (OR= 1.95 [95% CI; 1.30 - 2.93]).ConclusionsThis study demonstrated a strong association between mental illness and HCV chronic infection after adjusting for important confounders including other comorbid conditions. A growing body of research suggests that persons with mental illness are at increased risk for contracting and transmitting HCV due to high rates of substance use and high-risk sexual behavior among infected persons as well as high rates of sexual victimization. HCV prevention efforts should be directed toward individuals with mental illness or seeking treatment for mental illness.

A machine-learning algorithm to identify hepatitis C in health insurance claims data

ObjectiveWe developed a machine learning-based algorithm to identify patients with chronic hepatitis C infection in health insurance claims data.IntroductionHepatitis C virus (HCV) infection is a leading cause of liver disease-related morbidity and mortality in the United States. Monitoring the burden of chronic HCV infection requires robust methods to identify patients with infection. Insurance claims data are a potentially rich source of information about disease burden, but often lack the laboratory results necessary to define chronic HCV infection. We developed a machine learning-based algorithm to identify patients with chronic HCV infection using health insurance claims alone and compared it a previously developed ICD-9 code-based algorithm.MethodsWe obtained insurance claims, demographics, enrollment information, and hepatitis C laboratory results from the IBM MarketScan® Commercial Claims and Encounters databases. We defined chronic HCV infection cases as a patient with one or more positive HCV RNA result and required controls to have a negative HCV antibody result and no positive HCV RNA or antibody results. Patients were required to be continuously enrolled in a health insurance plan during the six months before and after the first positive or negative test result (index date). Outpatient and inpatient insurance claims for the six months before and after the index date were included in the analyses. The study period spanned from 2011 to 2014.Subjects were randomly divided into a training sample (80%) and test (20%) sample. We trained a random forest classifier using age, sex, region, Charlson comorbidity index, and variables defining the presence and frequency of 67 ICD-9 diagnosis codes and CPT procedure codes related to HCV and liver disease. We up-weighted cases to account for the low prevalence of infection in our sample. We generated forests of 1,000 trees for all models. The initial model included all variables. Permutation-based variable importance scores from this initial model were used to select variables for the final model. The previously developed algorithm defined chronic HCV infection as either two claims with codes for chronic hepatitis infection &gt; 60 days apart after an HCV RNA test claim or three claims with codes for chronic HCV infection on different dates after an HCV RNA test claim. We compared the predicted classification to HCV laboratory result-defined classification and calculated percent agreement, Kappa, sensitivity, specificity, positive predictive value, and negative predictive value. We then applied the final classifier to all individuals continuously enrolled in commercial and/or Medicare supplemental insurance to estimate the prevalence of chronic HCV infection in this population in 2014. Analyses were performed in SAS version 9.4.ResultsWe identified 5,780 (5.6%) cases with chronic HCV infection and 97,831 controls with negative HCV test results. The training dataset consisted of 82,888 individuals with approximately six million inpatient and outpatient claims. The final model included 23 variables related to hepatitis C (e.g., number of HCV RNA test claims), liver disease (e.g., cirrhosis diagnosis code), and comorbidities. In the training dataset, percent agreement, Kappa, sensitivity, specificity, positive predictive value, and negative predictive value were 99.2%, 0.92, 92.3%, 99.6%, 93.2%, and 99.5%, respectively. The presence of a CPT code for HCV RNA testing had the highest variable importance score. The test dataset included 20,723 individuals with approximately 1.5 million inpatient and outpatient claims. In the test dataset, percent agreement, Kappa, sensitivity, specificity, positive predictive value, and negative predictive value for the final classifier were 98.9%, 0.89, 89.9%, 99.4%, 89.0%, and 99.4%, respectively. Percent agreement, Kappa, sensitivity, specificity, positive predictive value, and negative predictive value for the previously developed algorithm were 96.3%, 0.50, 35.0%, 99.9%, 96.7%, 96.3%, respectively. Among the 35.6 million individuals with continuous commercial and/or Medicare supplemental insurance in 2014, 317,932 (0.9%) were classified as having chronic HCV infection.ConclusionsOur machine learning-based algorithm was able to identify chronic hepatitis C cases in commercial health insurance claims data with relatively high estimates for percent agreement, Kappa, sensitivity, specificity, positive predictive value, and negative predictive. Future analyses and models will explore the ability of the algorithm to estimate the prevalence of HCV infection in different populations covered by different health plan types (e.g., commercial, Medicaid, Medicare, or no insurance) and for populations where laboratory testing data is not available or collected.

Point-of-care hepatitis C testing from needle and syringe programs: An Australian feasibility study

BackgroundAchieving hepatitis C elimination requires novel approaches to engage people at highest risk of infection into care pathways. Point-of-care-tests may help to overcome some of the barriers preventing people who inject drugs (PWID) accessing testing and progressing to treatment for hepatitis C virus (HCV). We assessed the feasibility and acceptability of HCV point-of-care testing at needle and syringe exchange programs (NSPs) co-located in three community health clinics in Melbourne, Australia. MethodsNSP clients were offered an oral fluid point-of-care test for HCV antibody by NSP staff. Positive HCV antibody tests were followed by a point-of-care test for HCV RNA alongside standard-of-care laboratory testing for hepatitis C treatment work-up. Participants were offered same-day point-of-care results on site, via phone or text message, or upon return to the service. Participants were scheduled for follow-up review with the study nurse for assessment and linkage to treatment. ResultsA total of 174 participants completed HCV antibody point-of-care test; 150 (86%) had a reactive result. Of these, 140 (93%) underwent a HCV RNA point-of-care test and 76 (54%) tested positive; few participants (5%) waited on site for results delivery, but the majority of RNA positive (63%) attended a follow-up visit for treatment work-up (median time to follow-up visit = 11 days; IQR = 7–20 days). The majority of participants reported a preference for point-of-care tests (66%) and supported NSP staff involvement in testing (90%). ConclusionProvision of HCV point-of-care tests, follow-up and linkage to treatment services through NSPs was feasible and acceptable to PWID. Despite few participants waiting to receive same-day results, there was effective linkage to care, suggesting value in further evaluation of this approach.

High Yield of Active Tuberculosis Case Finding Among HIV-Infected Patients Using Xpert MTB/RIF Testing

ObjectiveConduct an active case finding study in Tbilisi, Georgia, for pulmonary tuberculosis (TB) among people living with HIV (PLWH).MethodsNewly diagnosed HIV patients were assessed for symptoms and asked to submit sputum samples for smear microscopy, culture, and molecular diagnostic testing (Xpert MTB/RIF).ResultsAmong 276 PLWH, 131 agreed to participate and 103 submitted sputum samples. Most participants were male (70%) and mean age of 43 years. There were high rates of a positive hepatitis C virus (HCV) antibody test (46%) and the median CD4 count was 122 cells/mm3. A total of 15 (11.5%) persons were diagnosed with pulmonary TB, including 1 each with multidrug-resistant and isoniazid-resistant disease. Twelve had a positive culture for Mycobacterium tuberculosis and Xpert TB/RIF assay, and 4 had positive smear microscopy. Patients with pulmonary TB were more likely to use injection drugs (67% vs 36%, P = .02) and have a positive HCV antibody (73% vs 42%, P = .02). The presence and absence of any TB symptom had a sensitivity and negative predictive value for TB of 93% and 98%, respectively.ConclusionOur findings highlight the high prevalence of TB among newly diagnosed HIV-infected patients in an area with high rates of drug-resistant TB and the utility of an active case finding strategy for TB diagnosis.

Prevalence of and risk factors for hepatitis C virus antibody among people who inject drugs in Cambodia: a national biological and behavioral survey

BackgroundHepatitis C virus (HCV) is a significant global health concern. Despite evidence of the relationship between injecting drug use and HCV, studies on HCV among people who inject drugs in developing countries remain scarce. To address this need, we conducted this study to explore the prevalence of and factors associated with HCV antibody positivity among people who inject drugs in Cambodia.MethodsData used for this study were collected as part of the National Integrated Biological and Behavioral Survey among people who use and inject drugs conducted in 2017. We used the respondent-driven sampling method to recruit participants in 12 provinces for face-to-face interviews and HIV and HCV antibody testing. Weighted multivariable logistic regression analysis was conducted to identify risk factors associated with HCV antibody positivity.ResultsThis study included 286 people who inject drugs with a mean age of 31.6 (SD = 7.5) years. The prevalence of HCV antibody among participants in this study was 30.4%, of whom 31.0% were co-infected with HIV. After adjustment for other covariates, the odds of HCV antibody positivity was significantly higher among participants who were in the older age group of 25 to 34 (AOR = 1.85, 95% CI = 1.06–7.92) and ≥ 35 (AOR = 2.67, 95% CI = 1.24–5.71), were in Vietnamese ethnic group (AOR = 5.44, 95% CI = 2.25–13.14), were living on the streets (AOR = 3.01, 95% CI = 1.29–704), had been sent to a drug rehabilitation center in the past 12 months (AOR = 2.67, 95% CI = 1.21–5.90), had received methadone maintenance therapy in the past 12 months (AOR = 3.02, 95% CI = 1.32–6.92), and were tested positive for HIV (AOR = 3.80, 95% CI = 1.58–9.12) compared to their respective reference group.ConclusionThe prevalence of HCV antibody among people who inject drugs in Cambodia is high, particularly in older and more vulnerable subgroups. Tailor-made interventions are required to increase access to culturally sensitive harm reduction interventions to prevent primary HCV infection and reinfection. In addition, there is an opportunity to expand screening, diagnosis, and treatment with new directly acting antiviral agents.

Test4HepC: Promoting Hepatitis C Testing to Baby Boomers Using Social Media.

Individuals born between 1945 and 1965 ("baby boomers") account for an estimated three quarters of all hepatitis C (HCV) infections in the United States. This article describes the evaluation of Test4HepC, a program that uses social media and a website to promote HCV testing to baby boomers in Los Angeles County, California. The first 16 months of Test4HepC were evaluated using an online survey (n = 302), qualitative interviews (n = 20), website and social media analytics, and records of free testing offered though the program. Test4HepC.org had 6,919 visitors; 48 individuals used the free testing offered. Within 1 month of visiting the website, 24.5% (74) of survey participants tested for HCV, 67.6% (50) received a negative HCV antibody test result, 2.7% (2) received a positive HCV antibody test result, and 25.7% (19) had not received their results as of taking the survey. Most of those not tested (60.5%) reported intention to test. In multivariable analysis, male sex and high perceived usefulness of the program website were associated with HCV testing. Qualitative interviews suggested that Test4HepC increased baby boomers' HCV risk perception and encouraged testing. Social media is a promising strategy for promoting HCV testing to baby boomers. Expanding Test4HepC to other areas and prioritizing the highest risk baby boomers could enable many people with HCV to benefit from new treatments.

Association between HCV infection and the incidence of Diabetes Mellitus in Egyptians

The present work was planned to find a correlation between HCV infection and diabetes mellitus (DM) incidence in Egyptian patients by finding a possible relationship between HCV antibodies and both anti-insulin antibodies (AIAs) and pancreatic islet cell antibodies (PICAs). The screening results showed that the percentage of HCV patients out of 200 subjects were 35.5 and 14.5% in males and females, respectively. Also, the association between DM and HCV were 13.21 and 13.64% in men and women, respectively. The titers of antibodies in diabetic or non-diabetic patients ranged from 30 - 58 for AIAs and from 30 - 40 for PICAs, The percentage of patients with raised serum transaminases was significantly more in DM patients with positive HCV antibody (52.3%) than DM patients with negative HCV antibody (16.7%). Conclusion, it can be concluded that diabetic or non-diabetic patients with HCV might have a rise titer of the antibodies toward insulin or its secretory cells in pancreas or toward both. where are more susceptible to both HCV-infection and antibodies than women, indicating to here is a significant association between HCV infection and induction of diabetes in Egyptians.

Seroreversion of positive anti-hepatitis C virus antibodies in left ventricular assist device recipients: Now you see them, now you don't.

The clinical significance of positive anti-hepatitis C virus (anti-HCV) antibody tests in recipients of left ventricular assist devices remains unclear. In light of emerging evidence suggesting the possibility of persistent low-level HCV infection in patients with positive anti-HCV antibody test but negative HCV ribonucleic acid, it is very important to distinguish the truly false positive HCV antibodies, in recipients of continuous flow left ventricular assist devices, from those suggestive of a prior clinically resolved infection or one where a low-level viremia may have persisted. We conducted a retrospective analysis of left ventricular assist device recipients at our institution. While the total incidence of positive HCV antibody with concomitantly negative HCV ribonucleic acid test (19.2%) was in keeping with the incidences reported in prior cross-sectional studies, we longitudinally followed our patients and observed a 100% seroreversion. Seroreversion, which has not been reported in other studies, occurred either during continued left ventricular assist device support (10 out of 26) or after heart transplant (7 out of 26). Hundred percent seroreversion strongly suggested that the anti-HCV antibodies were truly false positive.

Opportunistic assessment and treatment of people with hepatitis C virus infection admitted to hospital for other reasons: A prospective cohort study

BackgroundIt will be essential to find novel ways to access, diagnose and treat people with Hepatitis C Virus (HCV) infection in Australia to achieve HCV elimination. AimWe assessed the effectiveness of opportunistic HCV assessment and antiviral treatment in patients admitted to hospital for other reasons. MethodsPatients with HCV infection were referred from inpatient services at a tertiary referral centre in Sydney. Patients were assessed for HCV treatment with transient elastography (TE), HCV genotype and a clinical assessment and a summary letter was generated for all patients with a general practitioner (GP). Patients were offered treatment commencement at hospital discharge or after discharge with their GP, the infectious diseases clinic or with a gastroenterologist if they had cirrhosis. The primary outcome was the proportion of eligible patients who commenced treatment. We also undertook an intention to treat (ITT), modified intent to treat (mITT) analysis for virologic outcome (SVR12) and per protocol cure rates. An assessment of potential efficiency gains was undertaken. ResultsA total of 100 patients with a positive HCV antibody test were enrolled, of whom 70 were viraemic. The cohort included a high proportion of people who currently or previously injected drugs, indigenous patients and people previously lost to follow-up from other services. Treatment was initiated in 46 (66%) patients. The ITT was 80.4% (37/46) and mITT rate was 84.1% (37/44).The per-protocol SVR12 rate was 94.9%. Two subjects with genotype 3 and cirrhosis failed treatment, two subjects died and five were lost to follow up. The key barrier to uptake of DAA was incomplete assessment. Key inefficiencies of this model of care included referral of non-viraemic subjects, limited TE access and virologic test turnaround times. ConclusionThis model of care can complement the current efforts to increase HCV treatment in the community for those who do not access care elsewhere or are lost to follow-up.