Prevention in Focus

Spring 2021 

From the front lines: Integrating dried blood spot testing into community programs across Canada

Dried blood spot (DBS) testing is a method of blood collection that can be used for diagnostic hepatitis C and HIV testing. Samples are collected from a finger prick, dropped on to a filter paper and then dried for transportation to a laboratory. Dried blood spot testing for hepatitis C and HIV is as reliable and accurate as other blood-based testing methods. This approach may become more widely available in the coming years as it has the potential to complement existing testing options due to the ease of sample collection and stability of the collected sample.

We asked the following service providers about why they are using DBS testing, how it is being integrated into their programs and services, and the lessons they have learned:

  • Stefanie Materniak, Director of Operations, Centre for Research, Education & Clinical Care of At-Risk Populations (RECAP), New Brunswick
  • Raye St. Denis, Executive Director, Shining Mountains Living Community Services, Alberta
  • Kristin Lichty, Hepatitis C Treatment Nurse, North Lambton Community Health Centre, Ontario

Stefanie Materniak, Director of Operations

Centre for Research, Education & Clinical Care of At-Risk Populations (RECAP)

Why was dried blood spot testing implemented in your community? What needs were you trying to fill and what benefits did it offer? 

There were several reasons that we wished to pursue dried blood spot (DBS) testing at RECAP, but the most significant was aligned with our organization’s goal to decrease physical and psychological barriers for our patients within the healthcare system.

The implementation of DBS testing at RECAP offers many advantages:

  • It offers an alternative for patients with difficult vein access. In some patients, obtaining traditional blood work is greatly challenging because they have difficult vein access resulting from injection substance use. Previously, to confirm hepatitis C infection through RNA testing or obtain an updated viral load to proceed with treatment, we had to refer patients with difficult vein access to conventional hospital blood collection clinics, which have access to more specialized services. This often resulted in testing never being completed as patients were hesitant to go because of past negative experiences with stigma in the conventional healthcare system. DBS testing has provided our clinic a backup method of sample collection, ensuring that we can still obtain the information needed, even if traditional blood collection is unsuccessful.
  • It is faster than traditional blood collection: With traditional blood collection, it takes time to obtain the blood, complete the required paperwork and ensure the sample is properly transported to the local laboratory within the required time frame for processing. DBS testing is quick for the patient and the healthcare provider (HCP) and is free from the time constraints that come with traditional blood collection.
  • It fills a point-of-care (PoC) testing gap: Our clinic has used PoC testing for hepatitis C for several years; it is a quick and valuable tool that can provide same-day results for antibody tests, the first step in confirming a hepatitis C infection. A positive result on PoC testing has been shown to increase the likelihood that a person will continue to engage with us for subsequent visits and treatment. PoC testing as a first step in testing is not useful in those who have previously cleared hepatitis C because they will always remain antibody positive. DBS testing is easy to do regardless of the setting and provides a way to screen those previously infected with hepatitis C for RNA.

Can you describe your program? What strategies did you use to deliver dried blood spot testing in a way that met the needs of your community and encouraged people to take part? 

Our use of DBS testing coincided with the beginning of a hepatitis C outreach program for screening and treatment. The outreach program involved the movement of our HCPs to locations throughout our service area (which spans around 8,000 km2 in southern New Brunswick and includes several islands) to provide more convenient access to hepatitis C testing and treatment. Clinics took place in pharmacies, community centres, soup kitchens, food banks and community events, and for some of the clinics we partnered with local charitable organizations assisting populations who are often at increased risk for hepatitis C acquisition. Obtaining traditional blood work in these settings is challenging, if not impossible, because of the equipment needed, the facilities available and the requirements for transporting blood samples.

Among the 350 individuals we saw via the outreach program, we used DBS testing to:

  • obtain the updated viral loads of 15 patients with known positive RNA tests, bringing them a step closer to treatment initiation
  • rescreen 16 clients who had previously cleared the virus and find two reinfections
  • diagnose 14 new hepatitis C infections

We also used DBS in our clinic as a way to increase uptake of blood-borne pathogen screening (for both hepatitis C and HIV) by providing a quick and easy option for patients hesitant to have blood work done or not wishing to spend too much time having blood work obtained.

What lessons did you learn from implementing dried blood spot testing in this way? Did this approach fill the needs you were aiming to address? If so, what’s next?

Using DBS testing largely resolved the issues we were having with access to hepatitis C testing. However, we have identified two primary challenges.

Firstly, in New Brunswick, to proceed with hepatitis C treatment under the provincial prescription coverage program, we are required to provide a genotype of the virus, a recent viral load (obtained less than six months ago) and a fibrosis stage (which measures the level of scarring in the liver). The use of DBS testing has solved the issue of obtaining a viral load; however, obtaining a genotype still requires traditional blood work, as does fibrosis staging using clinical markers in the blood sample if a Fibroscan (a specialized ultrasound machine) is not available.

Secondly, outreach and linkage to care has been difficult in the rural communities we serve. In our outreach program, only 21% of the people we reached were from more rural areas, even though in some of these areas the rates of substance use are higher and there is a greater likelihood of hepatitis C transmission because of lack of access to safe supplies. We learned through talking to our clients that a possible reason for this is that the stigma associated with getting tested or accessing care in these communities is high. The arrival of COVID-19 restrictions has made outreach work even more challenging, particularly in rural areas where possible locations to conduct clinics were already scarce.

So, what is next? Collecting DBS samples at home. Beginning in January 2021 we will be launching a program for rural areas that will allow individuals to call, text or email to request a complete test kit with collection instructions, which will be mailed to their house in discreet packaging. A RECAP HCP will speak with them to provide pre-test counselling when they request a kit and will offer to provide support by phone when the test arrives to help guide them through the process and provide post-test counselling. Prepaid envelopes will be provided for individuals to mail the DBS card back to the clinic and once the results are received, the RECAP HCP will reach out with the results. If the test result is positive, all care and treatment can be arranged through the RECAP clinic through its connection with two local infectious disease physicians.

Raye St. Denis, Executive Director

Shining Mountains Living Community Services

Why was dried blood spot testing implemented in your community? What needs were you trying to fill and what benefits did it offer?

Shining Mountains Living Community Services (Shining Mountains) partnered with the Public Health Agency of Canada’s National Laboratory for HIV Reference Services in 2019 to take part in a research project to bring dried blood spot (DBS) testing to the community of Métis people we serve. Launched as part of the Drum & Sash project, our pilot aimed to better understand how Métis people living in Alberta would respond to and access alternative methods of testing. We wanted to use this information to improve the delivery of testing and care models for HIV and sexually transmitted and blood-borne infections across a wide range of city and rural settings.

Can you describe your program? What strategies did you use to deliver dried blood spot testing in a way that met the needs of your community and encouraged people to take part?

Shining Mountains has been operating in Red Deer, Alberta, for over 20 years and provides services to people experiencing or at risk for HIV, hepatitis C, domestic or intimate partner violence, and addictions. We prioritize the physical, mental, emotional and spiritual health of Aboriginal people in a wide range of environments in Central Alberta (e.g., city, rural). A strength of Shining Mountains is that it is owned, operated and staffed by Aboriginal people.

We worked with the Métis Nation of Alberta to implement the pilot project in ways that would meet the needs of the community, bring DBS testing into pre-existing events and Aboriginal spaces, and prioritize the participation and perspectives of Métis people.

This was achieved by building DBS testing into pre-existing events that Métis people were known to attend. The pilot was launched in Red Deer with leadership representation from the Métis Nation of Alberta. Breaking bread is an important component of Indigenous functions and our event planners made sure that there was food available for those attending. Shining Mountains staff were trained to offer education on what DBS testing was and how it was conducted, as well as answer any other questions that those attending had. For those who chose to be tested, we ensured that Métis people conducted the actual testing.

What lessons did you learn from implementing dried blood spot testing in this way? Did this approach fill the needs you were aiming to address? If so, what’s next?

Many working pieces were needed to make this project a reality and many lessons were learned along the way. The biggest lesson is that Métis people must be involved in every step of projects that involve our population.

To be successful, the DBS testing pilot had to be shaped by the experiences and voices of Métis people. There was a learning curve as we had to reiterate the needs of Métis people throughout the planning and implementation of the project. We had to be strong and stand up for the rights of the people we serve to maintain ongoing ownership of and influence over the project when working with non-Aboriginal services. In the delivery of the pilot, the participation of Shining Mountains staff and Métis people was essential for the success of these events. Evaluations were critical in showing the need and capturing the larger picture of how our community responded to this form of testing. This engagement in every step of the project was vital in ensuring that we were engaged in a way that is right and effective for our community.

Secondly, well-functioning and collaborative partnerships with organizations such as Alberta Health Services were vital. Through the project, Shining Mountains developed a broader understanding of how Alberta Health Services works and how important it is to have connections in many different regions of Alberta for a program to roll out effectively.

Kristin Lichty, Hepatitis C Treatment Nurse

North Lambton Community Health Centre

Why was dried blood spot testing implemented in your community? What needs were you trying to fill and what benefits did it offer? 

Our Hepatitis C Care Team encountered challenges processing traditional hepatitis C RNA (collected through blood drawn from the vein) within the appropriate time frame according to Public Health Ontario collection guidelines. This is because our community health centre serves several rural communities over a large geographic area and transportation of samples to laboratory services is a challenge, as samples are required to be frozen for travel. In addition, when our staff collected blood-drawn samples in some of the rural communities we serve, they had to make long trips to the centre at the end of day to process the samples in time, which proved to be an inefficient use of their time.

We also encountered other common challenges to collecting blood from the vein. Challenges included obtaining samples from clients with difficult vein access, obtaining samples from those with a reluctance to have blood drawn and performing blood draws in low light or untraditional settings such as outdoor testing pop-ups. Clients who use our hepatitis C and harm reduction services tend to have transient housing situations, often moving frequently between shelters, motels, encampments, etc. This resulted in a lapse between hepatitis C antibody and RNA testing, as some people were being lost to follow-up.

The introduction of dried blood spot (DBS) samples has helped us overcome these challenges. In addition, DBS testing has been beneficial as these tests require much less processing time than a traditional blood draw and storage of samples is easy. This has resulted in more time being available for outreach and direct client care.

Can you describe your program? What strategies did you use to deliver dried blood spot testing in a way that met the needs of your community and encouraged people to take part? 

Our program provides hepatitis C services (e.g., treatment and support) and harm reduction services including a needle syringe program. We are based in a rural community health centre and the clients we serve are spread out geographically.

We offer services primarily through street outreach and by partnering with other agencies to reach clients where they gather. We do offer in-house appointments, but our rural location means that public transportation is very limited. We have had the greatest success reaching service users by partnering with other agencies including local shelters, food banks, soup kitchens, our local jail and methadone programs.

Our team offers several hepatitis C testing pop-up events per month at varying locations. At these events, we offer hepatitis C testing, including both point-of-care antibody and DBS RNA testing. We also provide counselling, harm reduction services and peer support.

Our goal is to offer a quick turnaround for hepatitis C DBS testing with every reactive hepatitis C point-of-care antibody test. This is meant to reduce the number of clients who have had a positive antibody test but have never had a hepatitis C RNA test. DBS collection allows us to diagnose current hepatitis C infections without needing to draw any blood.1

Using DBS card collection to test hepatitis C RNA has increased the number of locations and times we can provide hepatitis C testing. Storage of samples is simple, the amount of equipment needed is much less than when we draw blood from the vein, and as blood does not need to be stored or analyzed right away, testing pop-ups can be run after laboratory hours.

What lessons did you learn from implementing dried blood spot testing in this way? Did this approach fill the needs you were aiming to address? If so, what’s next?

DBS testing has been incredibly beneficial for our team and the clients we serve. For our clients who are abstaining from intravenous drug use or who have very difficult vein access, having the option of finding out their hepatitis C status without having blood drawn has been very positively received. Clients have also provided very positive feedback about the ability to provide a sample to be tested for hepatitis C RNA immediately after having a reactive point-of-care antibody result.

Although the collection of DBS samples does have advantages over traditional blood draws in many settings, such as low-light and outreach settings, it is not without challenges. For a sample to be tested, four spots on the card must be filled completely. Obtaining enough blood to fill these spots can be difficult when the client’s hands are cold, or when they have very calloused fingers. In these situations, multiple finger pokes are often required. When it is difficult or impossible to get a capillary finger-poke sample, we have had success collecting a blood sample from the vein and transferring blood to a DBS card.

For our team serving clients in a rural area, DBS card collection has filled some of the gaps in care we encountered when assessing the needs of our clients. Looking toward the future, we would like to explore opportunities for task shifting – providing training to outreach and peer support workers to collect DBS samples. Our hope is that this would further increase access to hepatitis C testing for service users.

  • 1. The Public Health Ontario (PHO) Laboratory accepts the submission of dried blood spots (DBS) for the purposes of hepatitis C virus RNA detection.  DBS samples are only accepted for clients who have had a confirmed hepatitis C antibody result (from the PHO Lab or POC test) AND for clients who are either unable to provide a blood sample collected from the vein or who are located in remote and/or isolated locations with limited or no laboratory capacity.