Faculty Bibliography

Background. High volumes of hepatitis C (HCV)-infected detainees pass through US jails. However, short lengths of stay and competing priorities upon release complicate linkage to HCV care. We investigated linkage rates for patients with HCV following release from New York City (NYC) jails and describe a care coordination program (CCP) we initiated in June 2015 to improve linkage rates. Methods. We conducted a pre- and post-intervention study to assess rates of linkage related to the CCP. We used NYC Department of Health surveillance data to assess pre-intervention linkage rates for patients with chronic HCV seen in a correctional health clinic at Bellevue Hospital Center from January 2014 to June 2015. Linkage was defined as an HCV viral load or genotype <90 days in the community after release from an index incarceration. The CCP consists of a needs assessment, HCV education, and appointment scheduling for detainees, followed by reminder calls and appointment escort by a community patient navigator after re-entry. Statistical significance was determined using x2 tests. Results. Of 52 patients in the pre-intervention group, 24 (46.2%) were released from their index jail stay. Of those released, 10 of 24 (42%) were reincarcerated within a median of 247 days (IQR 129-318). The remaining 28 individuals were not released from their index incarceration and transferred to state prison. Of the 26 enrolled in the CCP as of April 2016, 13 (50%) have been released (6 linked, 4 pending linkage, and 3 not linked), 9 (34.6%) have not yet been released, and 4 (15.4%) have been transferred to state prison. Criteria for linkage to care within <90 days in the pre-intervention and intervention groups, respectively, were met by 3 of 24 (12.5%) versus 5 of 9 thus far (55.6%) (p = 0.01) and overall by 11 of 24 (45.8%) versus 6 of 9 thus far (66.7%) (p = 0.29). Conclusion. Pre-intervention linkage rates were low among HCV-infected detainees. While this study is ongoing, linkage in <90 days was significantly higher in the intervention group though not overall. These data provide early evidence that an integrated community-based CCP with jail-based transitional care coordinators may be effective in improving timely linkage to HCV care following release from jail

Background. Only half of the 3.5 million individuals with chronic hepatitis C (HCV) in the US are aware of their infection. Emergency departments (ED) provide a primary point of entry to the healthcare system for marginalized populations who are traditionally at elevated risk for HCV and are becoming an important venue for screening and linkage efforts. Optimal methods for HCV screening (universal versus targeted) in ED remain undefined. We aim to ascertain the relative prevalence of HCV infection by age and other risk factors through non-targeted screening for HCV in our high-volume urban ED. Methods. In this ongoing prospective observational cohort study, consenting adult ED patients participate in a researcher-administered structured interview and are offered a rapid HCV antibody (HCV Ab) screening test. If reactive, confirmatory serologic HCV Ab and HCV RNA are sent immediately and a clinic appointment is scheduled within 4 weeks. Participants are contacted with HCV RNA PCR results; those with detectable viral load are encouraged to attend follow-up appointment and receive a reminder call one week prior to appointment. Successful linkage to care is defined as appointment attendance. Results. A total of 2018 eligible patients were approached July 2015-April 2016. Seven hundred thirty-two participated in a structured interview. Seven hundred seven accepted an HCVAb rapid test. HCV antibody prevalence in the ED was 3.8% (0.43% in non-baby boomers without injection drug use (IDU), 7.6% in baby boomers, 34% in persons endorsing IDU). Twenty-three HCVAb-reactive participants submitted blood for confirmatory testing. A total of 12 of 23 (52%) had detectable HCV RNA, corresponding to 1.7% prevalence of chronic infection. Targeted screening of the birth cohort and those with IDU would have missed 7.4% (2 of 27) of HCVAb positive patients and 8.3% (1 of 12) with chronic infection. A total of 4 of 12 (33.3%) with chronic infection were linked to care, 2 have upcoming appointments, 1 died before appointment. Conclusion. Prevalence of HCV in our ED was higher than the national estimate of 3.4% among baby boomers used to justify national birth cohort screening. Optimal ED HCV screening methods should target baby boomers and those endorsing IDU, but a modest proportion of infections will be missed without universal screening

We investigated the duration of Ebola virus (EBOV) ribonucleic acid (RNA) and infectious EBOV in semen specimens of five Ebola virus disease (EVD) survivors. EBOV RNA and infectious EBOV was detected by real-time RT-PCR and virus culture out to 290 days and 70 days, respectively after EVD onset.

BACKGROUND: Sub-Saharan African nations have among the highest rates of chronic hepatitis B virus (HBV) infection worldwide, but little is known about HBV infection in African-born persons in the United States. METHODS: From October 2011 to July 2013, community-based HBV screenings were conducted targeting persons originating from Africa in New York City. Persons were identified as currently HBV infected (HBsAg positive) or exposed (HBcAb positive). RESULTS: Overall, 955 persons were screened for HBV; the median age was 45 years (interquartile range, 35-54 years) and 75.5% were men. Of these, 919 persons had no history of liver disease, of whom 9.6% (n = 88) had current HBV infection and 73.9% (n = 679) had exposure. In logistic regression, older age (odds ratio [OR], 0.97; 95% confidence interval [CI], .94-.99; P < .01) and female sex (OR, 0.35; 95% CI, .14-.75; P < .01) were less likely to be associated with HBV infection, whereas having a mother with hepatitis was associated with infection (OR, 18.8; 95% CI, 2.72-164.65; P < .01). HBV exposure was associated with older age (OR, 1.03; 95% CI, 1.01-1.04; P < .01), whereas female sex (OR, 0.46; 95% CI, .33-.66; P < .01) and history of blood transfusion (OR, 0.43; 95% CI, .22-.83; P = .01) were negatively associated. A patient navigator linked 97% of infected persons to care. Eleven persons were recommended for treatment, of whom 9 (82%) started therapy. Three persons were diagnosed with hepatocellular carcinoma on the first screening ultrasound. CONCLUSIONS: The high burden of HBV infection among African immigrants in the United States underscores a need for continued screening and linkage to care in this at-risk population.

BACKGROUND: 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). OBJECTIVES: 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. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.

INTRODUCTION: The US Preventive Services Task Force recommends one-time screening of the 1945-1965 birth cohort (baby boomers) for hepatitis C (HCV) infection. New York State legislation mandates screening of baby boomers for HCV in most patient care settings except the emergency department (ED). This cross-sectional study explores baby boomer knowledge of HCV, prevalence of HCV infection, and linkage to care from a large urban ED. METHOD: Patients participated in a researcher-administered structured interview and were offered an HCV screening test. If HCV antibody reactive, a follow-up clinic appointment was made within 6 weeks. Reminder telephone calls were made a week before the appointment. Attendance at the follow-up appointment was considered successful linkage to care. RESULTS: A total of 915 eligible patients were approached between October 21, 2014, and July 13, 2015. A total of 427 patients participated in the structured interview; 383 agreed to an HCV rapid test. Prevalence of HCV antibody reactivity was 7.3%. Four patients were successfully linked to care. General knowledge about HCV was fair. Misconceptions about transmission were apparent. Beliefs that "if someone is infected with HCV they will most likely carry the virus all their lives unless treated" and that "someone with hepatitis can look and feel fine" were significantly associated with agreement to testing. CONCLUSIONS: Better linkage to care is needed to justify HCV screening in the 1945-1965 birth cohort in this particular ED setting. Linkage to care from the ED is challenging but can potentially be improved with specific measures including simplified screening algorithms and supportive resources.