Professor Colm Bergin Consultant Physician in Infectious Diseases, St. James’s Hospital, Dublin. Clinical Professor of Medicine, Trinity College DublinAssociate Director, Wellcome Trust-HRB Clinical Research Facility at St. James’s Hospital, Dublin. Dean of Postgraduate Specialist Training, Royal College of Physicians, Ireland.

1. Professor Colm Bergin
Consultant Physician in Infectious Diseases, St. James’s Hospital, Dublin
Clinical Professor of Medicine, Trinity College Dublin
Associate Director, Wellcome Trust-HRB Clinical Research Facility at St. James’s Hospital, Dublin
Dean of Postgraduate Specialist Training, Royal College of Physicians, Ireland
cbergin@stjames.ie
Hepatitis C Infection
– Screening, Treatment and (as)
Prevention in the Community

3. Screening for HCV
• Why
• How
• Limited data
• Universal vs targeted
• Cost

4. Patientsin,000s
Prevalence Under Specialist CareDiagnosed Treated
HCV in Ireland
0
50
100
Data from Prof Norris, sourced from HPSC 2013, ICORN 2014, PCRS 2013.
35,000
12,365
8,000
1,942
15.7%

5. Number of notifications of hepatitis C 2004-2010, by
sex and mean age
Hepatitis C in Ireland
By 2013, 12,365 diagnosed
Prevalence is 20,000-50,000

6. Most likely risk factor (%) for cases of hepatitis C notified in
2012 (where data available, n=651, 63%)
Health Protection Surveillance Centre. Hepatitis C. May 2013.

7. Mean annual notification rates per 100,000 for hepatitis C by
age and sex, 2004–2012
Health Protection Surveillance Centre. Hepatitis C. May 2013.

8. • 36 recommendations
across four key
areas:
– Surveillance
– Education &
Prevention
– Screening
– Treatment access &
delivery

9. Current Challenges: Knowledge Gaps
• Epidemiological gaps
– Improving routine surveillance system R1,3
– Population prevalence study R6
– Historical trends in HCV diagnoses
– Modelling exercise to estimate burden of disease R7
– Follow-up studies among IDUs to identify seroconverters R8
– Connectivity between existing registries (methadone, S.I) to
facilitate national register R4
• Screening gaps
– Targeted antenatal screening, ?universal R27
– Promote screening for attendees of harm-reduction services
R28
– Guidelines re screening new entrants to Irish HCS R26

10. • 36 recommendations
across four key areas:
– Surveillance
– Education & Prevention
– Screening
– Treatment access & delivery
Recognises need
for a national
hepatitis C register
• To determine true prevalence,
acquisition risks & treatment
progress

11. Current Challenges - unmet need
General Population – Population Health : Education
Unknown Status – HCV Negative – High Risk
Unknown Status – HCV positive
HCV positive – Not engaged in care
HCV Positive – Engaged in Care
Therapeutics
Diagnostics
Location of Care
MDT
Late
Presenters
•Cirrhosis
•Liver cancer
•ICU & hospital
•Transmissions
Model of Care
•IDUs
•Migrants
•Prisioners
Complications
Universal
Or
Targeted
Testing
Prevention
EXCEL-1 :2012 – Hepatitis C Infection
Courtesy of Prof C Bergin

12. HCV in Ireland: where is it?
•Current injectors
• Ex-injectors
• Hidden
• Finding them may take a screening campaign
(‘baby boomers’)
•Immigrants
• Pattern of infection unpredictable (‘healthy migrant’ effect)
•Access can be difficult

13. Screening for HCV
• Why
• How
• Limited data
• Universal vs targeted
• Cost

19. Emergency Department Screening
for Blood Borne Virus InfectionS
EDVS Study
Principal Investigators:
Prof Colm Bergin, GUIDE, St James’s Hospital
Prof Suzanne Norris Dept of Hepatology, St James’s Hospital
Dr Catherine Fleming, Dr Helen Tuite, Dept of Infectious Diseases,
UCHG
Co-investigators:
GUIDE: Dr. Sarah O’Connell
Emergency Medicine - Prof Patrick Plunkett, Dr Una Geary, Dr
Darragh Shields, Dr Geraldine McMahon, Dr Darren Lillis, Dr Karl
Kavanagh,
Microbiology: Dr Brendan Crowley, Ms Helen Barry, Ms Linda Dalby
Study Co-ordinator: Ms Siobhan O’Dea

20. HIV, Ireland 2014
• 2013 – 344 new
diagnoses – 7.5 per
100,0001
• Incidence increasing in
MSM risk group
• 25% CD4 T-cell count
<200 cells/mm3
• Estimated 30%
unaware of status 2
1. Health Protection Surveillance Centre. HIV in Ireland, 2013. Dublin: Health Protection Surveillance Centre; 2014
2. Branson BM et al MMWR 2006

21. Mayo
Beaumont
Hospital
Prof.Samuel Mc
Conkey
Mater
Hospital
Dr. Patrick Mallon
Mater
Hospital
Dr. Patrick Mallon
St. James’s
Hospital
Prof. Colm Bergin
Prof. Fiona Mulcahy
University College
Hospital Cork
Prof. Mary Horgan
Limerick
Regional
Hospital
Dr. Busi Mooka
University College
Hospital Galway
Dr. Catherine Fleming
Health Protection
Surveillance Centre
Dr. Aidan O’ Hora
Dr. Darina O’Flanagan
Ambulatory care
2.25 /1000
4. Tuite et al ECCMID 2012

22. CDC Guidelines
• HIV screening recommended for patients aged
13–64 years in all healthcare settings 2
“opt-out screening”
• Persons at high risk: Repeat annually
• Separate written consent for HIV testing should
not be required
• Intensive pre-test counseling should not be
required with HIV diagnostic testing or as part of
HIV screening programs in healthcare settings
2. Branson BM et al MMWR 2006

23. • Screening in medical assessment units
(RAPID Project) 5
– Only 14% of eligible patients took HIV tests
• Screening in ED 6
– Only 14% offered
– Mean proportion accepting test offered 63%
5. Burns et al. HIV Med 2013
6. Rayment et al HIV Med 2013
HIV Screening

24. EDVS Objectives
• To assess the feasibility and acceptability of such an
expanded approach to widespread testing in ED
departments
• Dublin and non-ED departments
• To determine prevalence of HIV, HBV and HCV in
patients attending the ED
• To determine current linkage to care
• To promptly link the newly diagnosed to services and re-
engage the known patients to care

25. • Official roll-out: March 2014
• 4 pilot days over a two week
period
• Comatose, intoxicated, very
unwell patients excluded
• Opt out basis
• Supplied with Information
Leaflet prior to bloods being
done
• Waiting area / Triage
Given by staff doing bloods
EDVS Methodology

26. ED Chart Stamp
Reminders at
shift change
ED Chart Stamp
Reminders at
shift change
ED Bloods
80% Target
EDVS Bloods
50% Target

27. ED Bloods
80% Target
EDVS Bloods
50% Target
Feedback to staff
Continued positive
reinforcement
Feedback to staff
Continued positive
reinforcement

28. • Random auditing of various days
• Patients excluded subtracted from
‘patients who had bloods done ‘…
EDVS – Audit
Week EDVS / all ED
(%)
EDVS / all eligible subjects
(%)
13 62.8 82.0
14 63.5 73.4
20 67.1 75.5
21 52.9 64.3
22 63.6 75.0
23 54.0 64.3

29. Week 20

30. Total ED Bloods
9016
Total EDVS
5299
HIV n=63
57 known
6 new
1.1/1000
HBV n=25
13 known
12 new
2.3/1000
HCV n=287
243 known
44 new
8.1/1000
EDVS – Week 20
53.6% Male
48 (33,66) years

31. EDVS
HPSC1
Incidence
EDVS
Incidence
EDVS
Prevalence
EDVS Prevalence
(18-64 years)
HIV 7.5/100,000 1.1/1000 11.9/1000 11.9/1000
Hepatitis B 12.6/100,000 2.3/1000 4.7/1000 4.3/1000
Hepatitis C 22.6/100,000 8.1/1000 54.2/1000 53.0/1000
1. HPSC, Infectious Disease Notifications in Ireland, 2004-
2013

32. EDVS
HPSC1
Incidence
EDVS
Incidence
EDVS
Prevalence
EDVS Prevalence
(18-64 years)
HIV 7.5/100,000 1.1/1000 11.9/1000 11.9/1000
Hepatitis B 12.6/100,000 2.3/1000 4.7/1000 4.3/1000
Hepatitis C 22.6/100,000 8.1/1000 54.2/1000 53.0/1000
1. HPSC, Infectious Disease Notifications in Ireland, 2004-
2013

33. Linkage to care
• HIV - 62/63 (98.27%) linked
• 6/6 (100%) of new patients are linked to care ✓
• 56/57 (98.1%) known patients are linked to care
• HBV – 24/25 (96.0%) linked
• 13/13 (100%) known patients are linked to care ✓
• 11/12 (92.0%) of newly diagnosed patients have
been successfully linked to care ✓

34. Linkage to care
• Known HCV
• 58% (n=141) of previously known linked at time ✓
• 42% (n=102) known not linked
• 70.5% now linked ✓
• With intervention of the study team, a total of 87.6% of known
patients are now linked to care ✓
• 32.5% presumed new patients linked to care ✓
• Follow up all patients including those patients of no fixed
abode or have no reliable contact details available to the
hospital is ongoing

35. Use of acute hospital services:
8 x higher
Life expectancy: 30 years shorter

36. Increased healthcare needs
Difficulty using existing services
Substance misuse disorders
Psychiatric Diseases
Migrants
Homeless
Inclusion Health
Primary care/Safety Net
Acute Hospital Services
Drug Treatment Centres
Homeless Services
Migrant Services
Public Health
Dept of Population Health,
TCD

37. • Extend programme to non-Dublin location (UCHG)
• Sustainability of programme (SJH)
• Cost-effectiveness analysis (NCEC)
• Inclusion Health (Dr Cliona NiCheallaigh, Dr Niamh Allen, Dr David
Robinson, Dr Ger McMahon, Prof Bergin)
• Plans for testing at GP sites
– GP/primary care: >90% acceptability 7
• National surveillance 8
– Subgroup established 2013 (Dr Thornton) to address guidelines
for HCV testing; submit to NCEC in 2016
Future
7. Personal communication, Dr M O’Kelly, Sept 2014
8. National Hepatitis C Strategy 2011-2014

39. Conclusion
• Data needed
– Registry
• Integrated model
• Partnership
• Innovative approach
• Critical to strategy of eradication