Hepatitis C and Innovative Public Health Practice

Ann Thomas MD, MPH

Ann Shindo, PhD, MSW, MPH, MS

Oregon Public Health Division

Prevalence of Anti-HCV* (US,1999–2002 NHANES**)• Overall prevalence

1.6%

• 2.7 million Americans chronically infected

• 48,000 Oregonians chronically infected

Source: Armstrong Ann Intern Med 2006;144:705-714

0%

1%

2%

3%

4%

5%

6%

7%

8%

Pre

vale

nce

of

anti

-HC

V

All 6-19 20-34 35-39 40-44 45-49 50-54 55+

Age Group (years)

MenWomen

* Hepatitis C Virus

** National Health and Nutrition Examination Survey

Source: CDC Sentinel Counties Study of Acute Viral Hepatitis

Surrogate testingof blood donors

Anti-HCV test(first generation)

licensed

Anti-HCV test(second generation)

licensed

1983 1985 1987 1989 1991 19930

5

10

15

20

25

Cas

es p

er 1

00,0

00Estimated Incidence of Acute HCV (US, 1982–1993)

Question

The biggest challenge in addressing HCV in my jurisdiction is:

A. Health providers' ignorance

B. Lack of resources for follow-up of cases

C. Lack of public awareness regarding the HCV epidemic

D. Stigma associated with HCV

Click on the down arrow if you can’t see the response choices.

• Incubation period: Virus detectable 1–2 weeksAntibodies 7–8 weeks

• Clinical illness: 30–40%

• Jaundice 20–30%

• Anorexia, malaise, 10–20%or abdominal pain

• Typical course: Asymptomatic for decades

HCV: Clinical Features

Cirrhosis17

Chronic85

Courtesy of Seeff, LB and Alter, HJ.s

Time

100

Resolve15

Stable68 Stable

13

Mortality4

80%

20%

75%

25%

15%

85%

Risk of Fatal Outcome in Persons Who Develop Hepatitis C Infection

Cirrhosis17

Chronic85

Courtesy of Seeff, LB and Alter, HJ.s

Time

100

Resolve15

Stable68 Stable

13

Mortality4

80%

20%

75%

25%

15%

85%

48,000 Oregonians

10,000

1,000–2,000

Risk of Fatal Outcome in Persons Who Develop Hepatitis C Infection

Costs of HCV

Nationally (1997 data)• $5.46 billion

• 33% direct

• 67% indirect

• Comparison: asthma, $5.8 billion spent in 1994

• HCV costs expected to double or triple by 2010–2020

Oregon Medicaid fee-for-service patients (2007 data)• Medication costs=$400,000 (doesn’t include office visits, dx testing, biopsies)

• OHSU performs 25 transplants for HCV annually, cost for first year = $300,000

Source: Leigh Arch Int Med 2001, 161:2231–2237; Oregon DHS OMAP, personal communication

*PWID: Persons Who Inject Drugs

**Other: Tattoo, pierced, employed in medical field

PWID*63%

Unknown 22%

High Risk Sex

10%

Other**

5%

Reported Risk Factors for Acute HCV Infection, Oregon, 2006–2007, n = 47

0 6 12 18 24 30 36 42 48 54 60 66 720

20

40

60

80

100

Ser

opre

vale

nce

(%)

Duration of Injecting (mo)

HCV

HBV

HIV

Risk of HCV, HBV,* and HIV Infection Among Persons Who Inject Drugs (PWID)

Garfein RS. Am J Public Health. 1996;86:655.

Baltimore 1983–1988

* Hepatitis B Virus

Source: Public Health Division, Oregon DHS

Hep C HIV0

10

20

30

40

50

60

70

Per

cen

tHepatitis C and HIV in Persons Who Inject Drugs, Oregon State Penitentiary, 1998

Prevalence of HCV, HBV, and HIV in Persons Dying of Injection Drug Overdose*

PercentNumber Positive/

Number Tested

Source: Public Health Division, Oregon DHS

*Oregon, Nov. 1999–Dec. 2001

HIV 3/97 3

HCV 68/94 72

HBV 30/84 36

HCV/HIV 1/84 1

HBV/HIV 0/84 0

HBV/HCV 26/84 33

All three 2/84 2

• Overall, 317/936 (32%) persons tested were HCV+

• Most important risk factor identified was injection drug use

Source: Public Health Division, Oregon DHS

0

10

20

30

40

50

60

Per

cent

(%

) P

ositi

ve

Overall PWID

Prevalence of HCV

Multnomah County Screening Program, 2000

Number Positive/ Number Tested Percentage

History of STI* 8/157 5

MSM** 2/187 1

Multiple sex partners 5/221 2

Exchanged sex for money or drugs 1/23 4

Prevalence of HCV in Different Risk GroupsAmong Non-PWIDs

Source: Multnomah County, 2000* Sexually Transmitted Infections** Men who have sex with men

Question

Prevalence of hepatitis C among Persons Who Inject Drugs (PWID) is higher outside the Portland-Metropolitan area:

A. True

B. False

Click on the down arrow if you can’t see the response choices.

Multnomah County HCV Registry Study, 2005–2006• 40% sample of patients with lab-confirmed HCV

reported to Multnomah County Health Department (MCHD)

• Contacted provider to obtain assent to contact patient*

• In-person or phone interview

• Demographics, risk factors, medical history, ability to access health care, addiction, and mental health issues

• Enrollment = 25%*Except if patient is seen in ED, inpatient, occupational health, blood bank, or outreach

Demographic Characteristics of Enrolled Subjects, n = 196

• Education• 50% with > high school education

• Income• 80% < $30,000

• Homeless• 25% homeless in past year

• Insurance• 37% with Medicaid• 24% uninsured

Addiction Issues

• 94% currently drinking alcohol

• 17% felt should cut down on drinking

• 10% felt guilty about drinking

• 10% had morning “eye-opener”

• 80% had ever injected drugs

• 21% injected in past year

Mental Health Issues

• Over 60% were diagnosed/treated for mental health issues (self-report)

• Of 86 who completed:

• Beck Depression Inventory• 30% met criteria for major depressive order

• Mood Disorder Questionnaire• 13% positive for bipolar disorder

2007–2008 Pilot HCV Seroprevalence Activities• 15 participating counties

• 2520 free HCV tests available

• Targeted HCV testing based on increased risk for infection

• 583 tests performed

• 128 (22%) anti-HCV positive specimens

Sex and Age Among HCV Positive Cases, n = 124

Nu

mb

er

of c

ase

s

Age group

0

5

10

15

20

25

30

35

40

45

0-19 20s 30s 40 and up

Men

Women

Race Among Anti-HCV Positive Cases, n = 128

White84%

Unknown

5%

Black 2%Asian 1%

Mixed 2%

American Indian/Alaska Native

6%

Question

Do you or some other division of your agency encounter persons who may be at risk for HCV during the course of daily work?

A. Yes

B. No

Click on the down arrow if you can’t see the response choices.

Prevalence of HCV Among PWID in Oregon, 2007

% Rural Population Percent HCV +

Marion 15% 20%

Benton 19% 40%

Lane 19% 38%

Jackson 22% 21%

Umatilla 30% 35%

Klamath 36% 21%

Linn 37% 33%

Deschutes 37% 31%

Coos 38% 17%

Douglas 42% 15%

Total 27%

NEX*

* Needle Exchange

• Surveillance nightmare

• Incidence declining, difficult to measure

• Large burden of chronic disease

• Prevalence in PWID much higher than for HIV

• Concomitant psychosocial issues present huge barriers to diagnosis and management

Summary

HCV Innovations

• Federal picture

• State picture

• Innovative program example

• More we can do?

Domestic HIV, Viral Hepatitis, STI, and TB Prevention Appropriated Funds

Total: $963.1 million

*Fiscal Year 2006

**Source: CDC

Domestic HIV 68%

STD 16%

TB

14%

Hepatitis 2%

HCV and Public Health Interventions: Federal Focus• National Center for HIV, Hepatitis, STD, TB

Prevention (NCHHSTP)

• Program Collaboration Service Integration (PCSI)

http://www.cdc.gov/nchhstp/programintegration/docs/PCSImeetingreportwithcover11-26%20_2.pdf

PCSI

Question

Which of the following are ways you could provide support to integration of HIV/viral hepatitis/STD service delivery in your agency?

A. Collaborate with managers in other divisions

B. Cross-train staff to support integrated work activities

C. Develop low-impact methods of one-stop-shop public health interventions that work for our diverse service delivery programs

D. All of the above

PCSI Bottom Line

One-stop-shop for core public health services for persons at risk for HIV, viral hepatitis, STDs, and TB

‘HIV, Hepatitis, STD’

Say it like it’s one word!

HCV and Public Health Interventions: State Focus• Surveillance

• Programs

• HCV screening

• Hepatitis A/B vaccine to high-risk adults

• Integration with HIV, STI, TB (when appropriate)

• Targeting the highest-risk adults in Oregon

Innovative Approaches Example: Marion County, Oregon• Marion County STI routinely clinic screens for

hepatitis vaccine for adults

• Vaccines are administered by immunization nurses at time of STI appointment

• On-demand HIV and HCV testing are provided through the HIV prevention section

Outcomes

June 2004 through October 2004

• 86 client records tracked in study log

• Age = 25.8

• 85% had insurance that could be billed

• 89% of vaccine eligible clients received verbal recommendation from nurse provider

• 64% received vaccine

Supports to Integrated Service Delivery

• Close proximity of services (STI next door to Immunology, HIV prevention down the hall)

• Sticker “tickler” system

• Pre-project communication and brainstorming

• Cross-training of administrative, nursing, and health education staff

Barriers to Integrated Service Delivery

• Remembering to screen each client at STI clinic (administrative)

• Unknown if single antigen or Twinrix indicated (administrative)

• Vaccine Administration Record completion (nurse)

• Learning new vaccine protocols (nurse)

Innovative Approaches Example: HIV Alliance, Eugene, Oregon• NEX outreach van 1 x per week under bridge

in semi-rural area:

• Medical provider: wound care

• Nurse practitioner: Twinrix A/B vaccine

• HCV screening: home access kits

• HIV testing: Orasure

• Referral services to actual people, not just agencies

Feasibility of PCSI in Oregon Local Health Departments• Very feasible if just one person willing to be the

shameless instigator to instigate integration

• Precedent set in urban and rural settings

• Cross-training of staff is necessary given ongoing public health budget cuts in Oregon (e.g., timber fund cuts)

Bottom Line of HCV Innovation: Moving Past Our Silo-ized PH Delivery Systems!

The only way to address the HCV epidemic is through integrated service delivery options like comprehensive services at LHDs and holistic health services through NEX programs.

Test!

Educate!

Vaccinate!

HCV + Individual Seeking

Treatment

Barriers to Medical Intervention

Drug-Based

Therapies

Micro

• Mental health

• Substance use

• Social support

Macro

• Stigma

• Health policies

• Federal funding streams

Barriers

Meso

• Housing

• CAM

• A/B vaccines