Emergency departments at the crossroads of intersecting epidemics (HIV, HCV, injection drug use and opioid overdose)—Estimating HCV incidence in an urban emergency department population
Abstract:High seroprevalence of HCV antibody (anti-HCV) is common among urban emergency department (ED) patients. Little is known regarding incidence of HCV infection in ED patients. We conducted a longitudinal chart-review (2003-2016) of a subset of ED patients between December 2015 and January 2016 (the ‘index period’) in an urban ED that began an ED-based HCV screening program since November 2015. Patients were eligible for inclusion if they presented to the ED during the ‘index period’ and had at least one negative… Show more
“…The observed declines in HCV incidence in young black males and females are consistent with reported declines in HCV incidence in a predominantly-black cohort of community-based people who inject drugs in Baltimore 43 . In addition, and consistent with our model-based estimates, the observed incidence of HCV between 2003 and 2016 was significantly higher in white ED patients as compared to black ED patients 44 . The observed declines in HCV incidence in young black populations compared to white populations were also seen recently in New York City (NYC) 45 .…”
Background: Our understanding of pathogens and disease transmission has improved dramatically over the past 100 years, but coinfection, how different pathogens interact with each other, remains a challenge. Cross-sectional serological studies including multiple pathogens offer a crucial insight into this problem. Methods: We use data from three cross-sectional serological surveys (in 2003, 2007 and 2013) in a Baltimore emergency department to predict the prevalence for HIV, hepatitis C virus (HCV) and herpes simplex virus, type 2 (HSV2), in a fourth survey (in 2016). We develop a mathematical model to make this prediction and to estimate the incidence of infection and coinfection in each age and ethnic group in each year. Results: Overall we find a much stronger age cohort effect than a time effect, so that, while incidence at a given age may decrease over time, individuals born at similar times experience a more constant force of infection over time. Conclusions: These results emphasise the importance of age-cohort counselling and early intervention while people are young. Our approach adds value to data such as these by providing age- and time-specific incidence estimates which could not be obtained any other way, and allows forecasting to enable future public health planning.
“…The observed declines in HCV incidence in young black males and females are consistent with reported declines in HCV incidence in a predominantly-black cohort of community-based people who inject drugs in Baltimore 43 . In addition, and consistent with our model-based estimates, the observed incidence of HCV between 2003 and 2016 was significantly higher in white ED patients as compared to black ED patients 44 . The observed declines in HCV incidence in young black populations compared to white populations were also seen recently in New York City (NYC) 45 .…”
Background: Our understanding of pathogens and disease transmission has improved dramatically over the past 100 years, but coinfection, how different pathogens interact with each other, remains a challenge. Cross-sectional serological studies including multiple pathogens offer a crucial insight into this problem. Methods: We use data from three cross-sectional serological surveys (in 2003, 2007 and 2013) in a Baltimore emergency department to predict the prevalence for HIV, hepatitis C virus (HCV) and herpes simplex virus, type 2 (HSV2), in a fourth survey (in 2016). We develop a mathematical model to make this prediction and to estimate the incidence of infection and coinfection in each age and ethnic group in each year. Results: Overall we find a much stronger age cohort effect than a time effect, so that, while incidence at a given age may decrease over time, individuals born at similar times experience a more constant force of infection over time. Conclusions: These results emphasise the importance of age-cohort counselling and early intervention while people are young. Our approach adds value to data such as these by providing age- and time-specific incidence estimates which could not be obtained any other way, and allows forecasting to enable future public health planning.
“…1,2 The increase in screening has led not only to the development of more efficient, validated screening tools, such as the Denver HIV Risk Score, 3,4 but also to co-testing for other chronic infections, such as hepatitis C virus, and highlights the importance of the ED's role in public health interventions. 5,6 The incidence of syphilis infections is on the rise, particularly among African American men and men who have sex with men, and it is reaching epidemic levels in these communities throughout the United States. 7 Although syphilis infection is relatively inexpensive to treat and cure and is a predictor for HIV infection among men and transgender women who have sex with men, 8 co-screening occurs infrequently in the ED setting.…”
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confidence: 99%
“…1,2 The increase in screening has led not only to the development of more efficient, validated screening tools, such as the Denver HIV Risk Score, 3,4 but also to co-testing for other chronic infections, such as hepatitis C virus, and highlights the importance of the ED’s role in public health interventions. 5,6…”
The incidence of syphilis infections is on the rise, particularly among African American men and men who have sex with men, and it is reaching epidemic levels in these communities throughout the United States. Although syphilis is relatively inexpensive to treat and cure and is a predictor for HIV incidence among men and transgender women who have sex with men, rates of co-screening for syphilis are low in the emergency department setting, with a dearth of literature on this topic since the 1990s and early 2000s. In this case study, we describe an operational model for routine syphilis screening implemented in June 2017 at the University Hospitals Cleveland Medical Center in Cleveland, Ohio. We describe the advantages of screening using a reverse testing algorithm rather than the traditional method and the necessity of partnering with the Cleveland Department of Public Health for both diagnostic and follow-up logistics.
“…The growing movement in social emergency medicine has recognized the ED as a critical access point for the timely screening of both acute and asymptomatic undiagnosed HIV. 29 Given the results of our study, validated clinical prediction tools 4,6 integrated into the electronic health record may prove beneficial and eliminate variability in provider testing patterns observed in this study. 30 Testing for HIV infection remains the first in a series of important interventions aimed at closing the undiagnosed gap, and emergency department-based screening for HIV infection continues to play an important role in this initiative, though with room for clinical knowledge improvements.…”
Introduction This study examines the association of the domains of knowledge for HIV and sexually transmitted infections (STIs) among emergency medicine providers (EP). Methods From February 2018 to March 2018, 75 EP (physicians, residents, and advanced practice providers) completed an anonymous, self-administered survey. The primary outcome of strength of correlation between HIV and STI sections of the survey was analyzed using Spearman’s rank-order coefficient. Results Respondents were physicians (54.6%), male (56%), Caucasian (83.7%), with eight years in practice (IQR: 2,16). Spearman’s correlation of HIV and STIs showed a weak positive correlation ( r = 0.35, p = 0.002). There was no association between HIV scores and provider type ( p = 0.67) or provider gender ( p = 0.89) as well as no association between STI scores and provider type ( p = 0.10) or provider gender ( p = 0.79). Conclusion The results of our study reveal that when presented with a patient at high risk for undiagnosed HIV or with undiagnosed symptomatic HIV infection, most providers either do not test or do not have HIV in the differential diagnosis. Similarly, knowledge of STIs is only weakly correlated with knowledge of HIV risk factors and symptomatic HIV infection. Further research and screening efforts may benefit by focusing on HIV education among emergency medicine providers.
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