The Journal of Emergency Medicine, Vol. 38, No. 3, pp.

401 405, 2010

Copyright 2010 Published by Elsevier Inc.
Printed in the USA
0736-4679/08 $see front matter

doi:10.1016/j.jemermed.2008.03.036

Public Health
in Emergency Medicine

PREVALENCE OF HEPATITIS C, HEPATITIS B, AND HUMAN

IMMUNODEFICIENCY VIRUS IN A GRAND RAPIDS, MICHIGAN
EMERGENCY DEPARTMENT
Mark R. Hall,

MD, MPH,*

Dale Ray,

MD,

and Julie A. Payne,

MPH

*Kent County Health Department, Grand Rapids, Michigan, Department of Emergency Medicine, Spectrum HealthBlodgett Campus,
Grand Rapids, Michigan, and Department of Epidemiology, Kent County Health Department, Grand Rapids, Michigan
Reprint Address: Mark R. Hall, MD, MPH, Kent County Health Department, 700 Fuller NE, Grand Rapids, MI 49503

e KeywordsHIV prevalence; hepatitis C prevalence;

hepatitis B prevalence; emergency

e AbstractObjective: The objective of this study is to

provide updated prevalence information on hepatitis C,
hepatitis B, and human immunodeficiency virus (HIV)
among patients in a high-volume emergency department
(ED) located in a medium-sized, Midwestern city. Background: This study provides updated information regarding the prevalence of the blood-borne pathogens hepatitis
C, hepatitis B, and HIV among ED patients. Prior studies of
this type have focused on large inner-city populations with
high incidence rates of blood-borne diseases. These studies
have limited applicability to other common ED settings.
Methods: A convenience sample of 404 patients was selected using blood previously drawn independent of the
study. Patient-identifying information was unlinked from
study results, which allowed waiver of informed consent
from the Institutional Review Board. This blood was then
tested for hepatitis C, hepatitis B, and HIV. Results: Prevalence of hepatitis C antibody was 4.0%, relative to the
overall US population prevalence of 1.8%. Hepatitis BsAg
was present in 0.7% and HIV prevalence was 0.8%. There
were no coinfections; therefore, there was a combined prevalence of blood-borne pathogens of 5.5%. Conclusions: The
combined prevalence of blood-borne pathogens of 5.5%
supports previous recommendations of universal precautions, particularly in settings where the overall prevalence
may be underestimated. 2010 Published by Elsevier
Inc.

INTRODUCTION
Many emergency care providers were surprised by the
results of one of the initial human immunodeficiency
virus (HIV) prevalence studies among emergency department (ED) patients. In 1988, Kelen described an
overall HIV prevalence of 6.0% in a Baltimore inner-city
hospital ED (1). In 1996, an overall HIV seroprevalence
of 12.9% was demonstrated in a Bronx, New York ED
(2). Other blood-borne pathogens were also studied and
found to be alarmingly high. Kelen also reported the
rates of hepatitis C and hepatitis B in a Baltimore ED and
found the prevalence to be 18% and 5%, respectively (3).
Although the results of these studies were sobering,
many emergency physicians considered how applicable
these results were to their own practice environment. Orr
and Sturm independently suggested that geography, patient population, and socioeconomic status should be
considered by emergency care providers when extrapolating data to other ED settings. Sturm recommended that
studies from EDs in many parts of the nation be performed, compared and collated so that the view of HIV
infection is not biased (4,5).

This study was fully funded by the Kent County Health

Department.

RECEIVED: 13 February 2008; FINAL

ACCEPTED: 26 March 2008

SUBMISSION RECEIVED:

5 March 2008;
401

402

M. R. Hall et al.

Furthermore, more than a decade has passed since the

reporting of the vast majority of the blood-borne pathogen prevalence studies. During this time frame, the number of people living with HIV and acquired immune
deficiency syndrome (AIDS) increased in the United
States (US) due to better therapy and increased immigration (6,7). At the same time, attempts to decrease the
transmission of blood-borne diseases have occurred. For
example, a national strategy to eliminate hepatitis B was
implemented; the US began screening the blood supply
for hepatitis C, and needle exchange programs increased
throughout the United States (6,8 10).
The objective of this study is to provide updated
prevalence information on hepatitis C, hepatitis B, and
HIV among patients in a high-volume ED located in a
medium-sized, Midwestern city. It also seeks to determine these rates in an ED practice setting that, although
common, has not been well represented in previous studies focused on larger inner-city populations.

black (37%). Intravenous drug users and men having sex

with men made up over 60% of cases. Twenty-two
percent (128) of HIV/AIDS patients were born in a
foreign country, with the bulk of these cases (53%) from
Africa.
Kent County acute hepatitis B data were not available.
Of reported cases, the majority of these patients were white
(15). Accurate local prevalence rates of hepatitis C are
difficult to determine because serologic tests cannot differentiate acute infection from past or chronic infection. Additionally, not all health departments are able to do the
time-consuming collection of additional test results to determine if a positive laboratory result constitutes an acute
case. US rates of acute cases of hepatitis C detected through
specific surveillance systems show declines since the 1980s.
The estimated US prevalence rate of hepatitis C was found
to be 1.8% in the National Health and Nutrition Examination Survey III (16). When Kent County data from 2003
2006 were examined by race, the majority of Kent County
cases were found to be white.

MATERIALS AND METHODS

Definitions
A medium-sized city was defined using the Brookings
Institution definition of cities ranked 101 through 200
based on their population in 1990 (11). The most recent
US census estimates of the largest incorporated places over
100,000 ranked Grand Rapids, Michigan as #105 (12).

Description of the Facility

The hospital is a level-one trauma center in a mediumsized city with an annual census of 119,498 patients in
2005 and 129,979 in 2006. It is one of four hospitals that
serve the city of Grand Rapids, in Kent County, Michigan. Each hospital serves inner-city, urban, and suburban
populations. Grand Rapids had a population size of
184,369 in 2006 (13). Grand Rapids is the second most
populous city in Michigan, after Detroit. The city of
Grand Rapids has a predominately white population
(67%) in which 23% of all individuals in the city live
below the poverty level (13).

Description of the Population

According to the epidemiologic profile of HIV/AIDS in
Michigan, Kent County had the second highest estimated
prevalence rate of HIV cases (0.2%) among Michigan
health departments (14). Of the patients in Kent County
with HIV, the majority were white (49%), followed by

Study Design
During a 4-month period, from June through September
2005, a prospective, anonymous, cross-sectional study of
hepatitis C, hepatitis B, and HIV prevalence was conducted. A non-consecutive convenience sample of 404
individuals was secured from extra blood specimens
previously obtained through the course of normal ED
operations. Age and gender were obtained from the samples, with only patients aged 1550 years included. The
age range for the study was selected for comparability to
other studies. Most studies of blood-borne pathogen
prevalence use a low age cutoff at or around 15 years
(15). The single study attempting to determine HIV
prevalence in a non-inner-city population used a similar
age range of 18 55 years (5). Duplicate patient entries
were excluded using Microsoft Access (Microsoft Corporation, Redmond, WA). All potential identifying information was removed from the samples and new study
numbers were assigned, with linkage only to the age and
gender data. All information was collected by one of the
two physician authors. The study design was for epidemiologic purposes, without the use or availability of
patient-specific test results. The informed consent requirement was therefore waived by the hospital Institutional Review Board.

Testing Procedure
Hepatitis C status was assessed by measurement of hepatitis C antibody. Active hepatitis B status was deter-

Hepatitis and HIV Prevalence

403

mined by assay for hepatitis B surface antigen HIV

antibody, determined through an enzyme-linked immunosorbent assay (ELISA). Positive HIV tests were confirmed by Western Blot.
RESULTS
During the study period, a total of 404 blood specimens
were collected. Table 1 shows that of the 404 specimens,
16 (3.96%) were positive for hepatitis C; 95% confidence
interval (CI) was 2.1%5.9%. Of 403 specimens, 3
(.74%) were positive for hepatitis B (95% CI 0.1%
1.6%). Of 393 specimens, 3 (.76%) were HIV positive
(95% CI 0.1%1.6%).
Differences in the number of samples tested are due to
the variable amount of sample available. HIV testing was
done last, and therefore had the most instances of insufficient sample (11). One case report of Hep C Ab was
indeterminate. Subsequent RNA amplification was negative, with the sample ultimately counted as negative.
There were no cases of positive HIV-ELISA samples
that were not confirmed by Western Blot. No sample was
positive for more than one test. Therefore, the prevalence
of any of these blood-borne pathogens in this sample was
5.45%. The lack of co-infection was at least partly due to
the very low prevalence of HIV and hepatitis B virus in
this study.
Tables 2 and 3 show demographic information that
was available for 22/22 (100%) of positive patients. Of
the entire study population, 55% were female and 45%
were male. The minimum age was 17 years and the
maximum age was 49. The mean age was 36 years. Of
those who had hepatitis C, 56% were female and 44%
were male. The positive patients ranged in age from 17 to
49 years; the mean age was 38 years. The number of
patients testing positive for hepatitis B and HIV was
insufficient to characterize.
DISCUSSION

Table 2. Gender and Age of HIV, Hepatitis B and C

Study Population

Gender
Female
Male
Total
Age (years)
1519
2029
3039
4049
Total

Number

Percent

12
10
22

55%
45%
100%

2
5
3
12
22

9%
22%
14%
55%
100%

other providers who are routinely exposed to unrecognized blood-borne pathogens. Most of the available prevalence data from the early 1980s and 1990s among
similar populations are outdated. Additionally, most previously described studies focused on inner-city populations, which may be less generalizable to many practice
settings.
Since the early 1990s, the annual number of newly
diagnosed HIV cases has remained stable (17). However,
because the number of individuals living with HIV has
increased, the actual risk of exposure to health care workers
is higher. HIV and hepatitis B posed lower exposure risks in
this study. It is hoped that national hepatitis B prenatal
prevention and HIV/AIDS educational programs have contributed to these lower risks. In this study, hepatitis C was
the dominant blood-borne infection. It is estimated that
55 85% of people infected with hepatitis C virus become
chronically infected, frequently progressing to cirrhosis or
liver cancer (18). It remains a leading cause of liver transplant, despite treatment advances shown with pegylated
interferon and ribavirin (19).
Although the prevalence of hepatitis B antigen is low
in this study, its high transmissibility (6 31%) still
brings significant risk after an exposure. The transmissibility rates of hepatitis C virus and HIV after a high-risk
needle-stick injury are 1.8% and 0.3%, respectively (20).

The overall prevalence of blood-borne pathogens,

5.45%, is of particular interest to emergency care and
Table 3. Gender and Age of Hepatitis C Study Population
Number

Percent

9
7
16

56%
44%
100%

1
3
2
10
16

6%
19%
13%
62%
100%

Table 1. Overall Prevalence Results

Hepatitis C Ab
Hepatitis Bs Ag
HIV
Hepatitis C,
Hepatitis B,
or HIV

Number
Tested

Number
Positive

Percent

Confidence
Interval

404
403
393
404

16
3
3
22

3.96
0.74
0.76
5.45

(2.15.9)
(0.11.6)
(0.11.6)
(3.27.7)

Gender
Female
Male
Total
Age (years)
419
2029
3039
4049
Total

404

M. R. Hall et al.

Limitations
This study had several limitations. The study used remaining blood from routine operations at a single ED.
Samples were selected on the basis of age, with those
younger than 15 years or older than 50 years excluded.
Consequently, it is unclear how these data could be used
to estimate the risk when the source is unknown, as with
a needle stick from the sharps container. It also is unclear
how these data could be applied to other populations such
as office patients, hospitalized patients, and even ED patients not undergoing blood sampling. Although the sample
size is relatively small, the lower prevalence of blood-borne
illness gives acceptable confidence intervals.

CONCLUSION
This study provides up-to-date data on the prevalence of
three potentially deadly blood-borne pathogens in an ED
that may be more representative than the data from prior
studies. Multiple studies have shown poor compliance
with universal precautions, even in settings when the
predicted risk of exposure is high. It is the authors
estimation that compliance is even worse in settings
where perceived risk is lower, perhaps an area for further
study (20). With an overall prevalence of 5.5%, this
study supports the continued consistent adherence to
universal precautions in ED populations, even when anticipated HIV prevalence is relatively low.

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N Engl J Med 1988;318:164550.
2. Alpert PL, Shuter J, DeShaw MG, Webber MP, Klein RS. Factors
associated with unrecognized HIV-1 infection in an inner-city
emergency department. Ann Emerg Med 1996;28:159 64.
3. Kelen GD, Green GB, Purcell RH, et al. Hepatitis B and hepatitis
C in emergency department patients. N Engl J Med 1992;326:
1399 404.

4. Orr MD, Hoos A, Riester DE, Gilcher RO, Meltz ML. Surveillance
for HIV antibody and antigen in trauma patients. J Emerg Med
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5. Sturm JT. HIV prevalence in a midwestern emergency department.
Ann Emerg Med 1991;20:276 8.
6. Jajosky RA, Hall PA, Adams DA, et al. Summary of notifiable
diseasesUnited States, 2004. MMWR Morb Mortal Wkly Rep
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7. Barnett ED. Infectious disease screening for refugees resettled in
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evidence from the 2000 census. Brookings Institution Survey Series 2002:117. Available at: http://www.brookings.edu/es/urban/
publications/veyformanmedcitiesexsum.htm. Accessed September
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12. US Census Bureau. Annual estimates of the population for incorporated places over 100,000, ranked by July 1, 2004 population. April 1,
2000 to July 1, 2004. Washington, DC: US Census Bureau; 2004.
13. US Census Bureau. 2006. American factfinder fact sheet for Grand
Rapids, MI. Available at. http://www.census.gov/. Accessed September 14, 2007.
14. Michigan Department of Community Health. 2006. Epidemiologic
profiles of HIV/AIDS in Michigan. Available at. http://www.
michigan.gov/mdch/0,1607,7-132-2944_5320-36307--,00.htm.
Accessed September 14, 2007.
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Hepatitis and HIV Prevalence

ARTICLE SUMMARY
1. Why is this topic important?
This topic is important because the overall prevalence
of blood-borne pathogens, 5.45%, is of particular interest
to emergency care and other providers who are routinely
exposed to unrecognized blood-borne pathogens.
2. What does this study attempt to show?
This study shows updated information regarding the
prevalence of the blood-borne pathogens hepatitis C,
hepatitis B, and HIV among emergency department (ED)
patients in a high volume ED located in a medium-sized,
Midwestern city.
3. What are the key findings?
The prevalence of hepatitis C antibody was 4.0%, the
prevalence of Hepatitis BsAg was 0.7%, and HIV prevalence was 0.8%. There were no coinfections; therefore,
there was a combined prevalence of blood-borne pathogens of 5.5%.
4. How is patient care impacted?
Universal precautions are cumbersome and frequently
breached. These data stress the need for adherence to
universal precautions, even in ED practice settings where
the perceived risk of exposure to blood-borne pathogens
is small.

405