The Overlooked Consequences of the COVID-19 Pandemic – What happened to ED-Based Hepatitis C Screening Programs?


The Overlooked Consequences of the COVID-19 Pandemic

What happened to ED-Based Hepatitis C Screening Programs?

Written by Sylvie Sontheimer, MD

Edited by Lauren Walter, MD

Throughout the COVID-19 pandemic news headlines across the nation have highlighted accounts of scarce medical resources, overwhelmed hospitals, and increasing death tolls. While the virus itself is responsible for millions of deaths and an even greater number of people burdened by ‘long COVID’ symptoms, it has also had far-reaching impacts on health systems as a whole. Emergency department (ED) volumes plummeted by up to 42% in some areas of the country during the early pandemic including dramatic decreases in ED visits for stroke, acute myocardial infarctions, and appendicitis. However, in concerning contrast, out-of-hospital mortality during the same time period increased (1,2). As such, it’s not that fewer people were having heart attacks or strokes, but rather they were deferring care during the pandemic and/or otherwise unable to access the healthcare system as they had pre-pandemic. The COVID-19 pandemic has had far reaching effects, impacting an extensive spectrum of non-COVID related acute and chronic disease processes and outcomes.

The disruption in healthcare and fluctuations in ED volumes have had even further implications that are not often considered. One that has been of particular personal interest is how COVID has impacted my home institution’s universal Hepatitis C (HCV) screening and linkage to care program, which had previously been well-established for nearly a decade. We conducted a retrospective chart review comparing screening and linkage rates in the pre-COVID time period (between January 2019 and October 2019) to the post-COVID time period (January 2020 to October 2020). Our institution’s ED volume decreased by 13.7% in the post-COVID time period, with an associated 19% reduction in HCV screening during the same time period. The incidence of individuals who were HCV-RNA positive remained nearly the same between the two time periods (2.8% of those screened were HCV-RNA positive in the pre-COVID time period, compared to 3.1% in the post-COVID time period, p = 0.98). What are the implications when the ED volume drops, but the HCV-RNA positivity rate remains the same? Simply put: We are missing valuable opportunities to screen people, leaving more people in the community unscreened, unaware of their HCV status, and able to transmit the virus to others and perpetuate the common infectious cause of death in the US. Intravenous drug use (IVDU) is one of the leading causes of transmission of HCV (linked to at least 1 in 5 cases) due to sharing of contaminated needles and syringes, and during the COVID-19 pandemic we’ve seen a dramatic uptick of substance use in the community (3,4). The combination of fewer individuals being screened for HCV and unaware of their HCV status coupled with an increase in substance use, is a dangerous one, with potential long-term effects for exponential spread of the virus. One study used mathematical models to predict the impact of a one-year delay in HCV diagnosis and treatment and estimates we will see an additional 44,800 cases of liver cancer and 72,300 additional deaths globally due to HCV by 2030 (5).

This case highlights how crucial ED-based screening programs are during public health crises, like the current pandemic. Some outpatient and primary care clinics were closed or resorted to telemedicine visits during the pandemic, eliminating the opportunity to screen patients for HCV in these settings. Even though our institution’s testing volume dropped by 19% during the pandemic, the ED was never closed and never bound to telemedicine appointments, enabling us to continue screening anyone who walked through the door. Additionally, due to our well-established linkage to care network, we did not see a significant difference in percentage of individuals who were successfully linked to HCV follow-up care in the post-COVID time period compared to the pre-COVID time period (p = 0.25).

It is imperative that we consider what can be done in the case of future pandemics or similar public health crises. One institution has employed point-of-care HCV testing at needle exchange sites, successfully identifying HCV positive patients and linking them to care (6). Perhaps it could be possible to expand point-of-care testing to including health departments, urgent care clinics, and other avenues that may remain open while primary care clinics are closed. Furthermore, mobile clinics have demonstrated success in offering HCV testing, which would allow people to seek testing options without having to travel to a hospital or clinic (7). It is imperative, that in times of future public health crises, we find ways to maintain preventive health screening and interventions, to included ED-based HCV screening programs, so that the burden of subsequent disease morbidity and mortality does not supersede previous public health accomplishments and progress.  



References:



  1. Hartnett KP, Kite-Powell A, DeVies J, et al. National Syndromic Surveillance Program Community of Practice. Impact of the COVID-19 Pandemic on Emergency Department Visits - United States, January 1, 2019-May 30, 2020. MMWR Morb Mortal Wkly Rep. 2020 Jun 12;69(23):699-704.

  2. Walker LE, Heaton HA, Monroe RJ, et al. Impact of the SARS-CoV-2 Pandemic on Emergency Department Presentations in an Integrated Health System. Mayo Clin Proc. 2020 Nov;95(11):2395-2407.

  3. Hepatitis C & Injection Drug Use. Centers for Disease Control and Prevention. https://www.cdc.gov/hepatitis/hcv/pdfs/factsheet-pwid.pdf. Accessed 15 June 2021.

  4. Czeisler MÉ, Lane RI, Petrosky E, et al. Mental Health, Substance Use, and Suicidal Ideation During the COVID-19 Pandemic - United States, June 24-30, 2020. MMWR Morb Mortal Wkly Rep. 2020 Aug 14;69(32):1049-1057.

  5. Blach S, Kondili LA, Aghemo A, et al. Impact of COVID-19 on global HCV elimination efforts. J Hepatol. 2021 Jan;74(1):31-36.

  6. Noller G, Bourke J. Point-of-care rapid testing for hepatitis C antibodies at New Zealand needle exchanges. N Z Med J. 2020 Nov 20;133(1525):84-95.

  7. Lazarus JV, Øvrehus A, Demant J, et al. The Copenhagen test and treat hepatitis C in a mobile clinic study: a protocol for an intervention study to enhance the HCV cascade of care for people who inject drugs (T'N'T HepC). BMJ Open. 2020 Nov 9;10(11):e039724.



John Purakal