By: Marcus J. Hopkins, Blogger
It is the conventional wisdom that the Southern United States play host to health epidemics of several sorts – obesity, premature deaths, diabetes, heart disease, higher risks of cancer… To say that health issues in the South are prevalent is to say that the Great Pyramid of Giza is a small rock formation. With all those troubles, South Carolina has a growing problem: liver cancer deaths.
In just six years (2010-2016 – the best available information) liver cancer deaths rose 43% in adults aged 25 and older. When you focus on age groups, adults aged 55-64 saw a staggering 109% increase (National Center for Health Statistics, 2018). The rate of death in South Carolina falls in the range of 10.0-11.9 (per 100,000 – the NCHS report doesn’t list the specific rates), putting it above the national average, and sadly, three other Southern states – Texas, Louisiana, and Mississippi – all have higher death rates from liver cancer.
This rise in liver cancer deaths conveniently (for lack of a better word) coincides with a sharp increase in the number of Hepatitis C (HCV) infections. HCV is a disease that specifically impacts hepatic (liver) health and function, and the NCHS report indicates that HCV is likely the greatest factor in this increase (Osby, 2018).
Essentially, part of why HCV incidence reporting is so finicky is that testing and screening protocols are not standardized across the U.S. Each state essentially establishes its own screening guidelines, and the vast majority have failed to update said guidelines to reflect the growing face of the epidemic at hand – Injection Drug Use (IDU). Certainly, the U.S. Centers for Disease Control & Prevention (CDC) recommends testing for anyone who is or has participated in IDU, but the reality is that few people are willing to come forward about those actions on a voluntary basis; how can a physician proactively test patients for HCV if they don’t disclose current or previous IDU?
One step to help identify HCV infections, for which HEAL Blog has advocated, is using emergency care settings as mandatory HCV screening locations. The thinking behind this is that, rather than attempting to ferret out potential IDU among patients, HCV testing should be offered to all Emergency Room (ER) patients, regardless of apparent risk factors. Heck, even a half measure of testing every overdose victim in emergent care situations (on 911 calls and ER arrivals, for example, using rapid testing and immediate linkage to care) would be better than the system we currently have in place.
More than just advocacy, research is bearing out this measure. In a study published in Academic Emergency Medicine, HCV tests were performed at Boston Medical Center on 3,808 patients at least 13 years old undergoing phlebotomy (blood work) for clinical purpose (Schechter-Perkins, et al., 2018). The tests were performed in a nontargeted, opt-out method, meaning that patients had to provide informed refusal of the test. The results of this three-month effort resulted in 292 confirmed positive HCV patients (7.7% of all patients tested).
While this number may sound low, the breakdown of those results is telling: 155 of those 292 (53%) fell outside the Birth Cohort (1945-1965) for whom the CDC recommends one-time HCV testing, 46 of whom reported no IDU as a risk for infection. The breakdown, post-testing, occurred (as it usually does) with attempted linkage to care: linkage attempts were documented on 223 76.4% of those identified as testing positive for HCV, and follow-up appointments were scheduled for 102 (38% of attempted linkages). Only 66 out of 292 attended that follow-up appointment (22.5% of all RNA-positive patients).
So…is it the best solution? Potentially, given the abject failure of state and national politicians to grasp the severity of this epidemic and respond to it with even adequate increases in funding. A few states – California, for example – have responded for those on their Medicaid rosters, but only in terms of affording treatment. How do we treat people who haven’t been tested, particularly if there’s insufficient funding for testing? It’s all going to take money, and if we don’t pony up the costs ahead of time, it’s going to cost all of us exponentially more – in both financial, and human terms – further down the line.
- National Center for Health Statistics. (2018, July). Trends in Liver Cancer Mortality Among Adults Aged 25 and Over in the United States, 2000–2016, NCHS Data Brief, No. 314. Atlanta, GA: United States Department of Health and Human Services: Centers for Disease Control and Prevention: National Center for Health Statistics. Retrieved from: https://www.cdc.gov/nchs/data/databriefs/db314.pdf
- Osby, L. (2018, July 23). Liver cancer deaths soar in South Carolina, across the US. Greenville, SC: The Greenville News. Retrieved from: https://www.greenvilleonline.com/story/news/2018/07/23/liver-cancer-deaths-soar-sc-nation/806045002/
- Schechter-Perkins, E.M., Miller, N.S., Hall, J., Hartman, J.J., Dorfman, D.H., Andry, C., & Linas, B.P. (2018, May 31). Implementation and Preliminary Results of an Emergency Department Nontargeted, Opt‐out Hepatitis C Virus Screening Program. Academic Emergency Medicine. https://doi.org/10.1111/acem.13484
Disclaimer: HEAL Blogs do not necessarily reflect the views of the Community Access National Network (CANN), but rather they provide a neutral platform whereby the author serves to promote open, honest discussion about Hepatitis-related issues and updates. Please note that the content of some of the HEAL Blogs might be graphic due to the nature of the issues being addressed in it.