Emergency Department Hepatitis C Screening Among Former Soviet Union Immigrants: When International Best Practices Meet Local Realities

Background: International studies demonstrate emergency department (ED)-based hepatitis C virus (HCV) screening achieves higher detection rates and better linkage-to-care than community screening. We tested whether these benefits would extend to Former Soviet Union (FSU) immigrants in Israel, a high-risk population with historically variable screening in primary care. Methods: Two-phase mixed-methods study at Wolfson Medical Center (June 2023-August 2025). Phase 1: Prospective HCV screening offered systematically to FSU immigrants aged ≥18 presenting to the ED, hypothesizing improved case detection based on international evidence. Phase 2: Following unexpected low participation, systematic barrier analysis including staff interviews (n=18), chart reviews (n=307), community interviews (n=8), and economic evaluation. Results: Unlike international experiences, ED screening failed dramatically. Of 970 eligible patients, only 243 (25.1%) completed screening. Among screened, HCV seroprevalence was 3.3% (8/243) with one viremic case who died before treatment. Phase 2 revealed population-specific barriers: mistrust of medical authority (31.1% of refusals), rooted in Soviet-era medical trauma; fear of diagnosis consequences (23.9%); and wellness perception (22.2%). Refusers were more likely to present during evening hours (64.5% vs 35.8%, p<0.001) and have shorter stays (median 2.1 vs 4.7 hours, p<0.001). Conclusions: ED-based HCV screening, despite international success, failed in FSU immigrants due to unique historical and cultural barriers. These findings challenge the universal applicability of ED screening strategies and emphasize the need for population-specific evaluation before implementing internationally validated interventions. For populations with medical system trauma, community-based approaches may be essential regardless of international best practices.