Viral Hepatitis Testing Initiative - Sharing Results · NASTAD Webinar March 11, 2014 ... Anti-HCV...
Transcript of Viral Hepatitis Testing Initiative - Sharing Results · NASTAD Webinar March 11, 2014 ... Anti-HCV...
Viral Hepatitis Testing Initiative - Sharing Results
March 11, 2014
Mission NASTAD strengthens state and territory-based leadership,
expertise and advocacy and brings them to bear on reducing the incidence of HIV and viral hepatitis infections and on providing care and support to all who live with HIV/AIDS and viral hepatitis.
Vision NASTAD’s vision is a world free of HIV/AIDS and viral hepatitis.
Who is NASTAD?
Table of Contents
Testing Initiative Overview
Presentations by Grantees
– Denver Health and Hospital Authority, Denver, CO – Alia Al-Tayyib
– MedStar Research Institute, Washington, DC – Dawn Fishbein
– Ohio Asian American Health Coalition, Columbus, OH – Manju Sankarappa
Viral Hepatitis PPHF Testing Initiative
Established in FY2012, out of the Prevention and Public Health Fund
$6.7 million to 32 grantees in the following categories:
– HBV identification and linkage to care among foreign-born persons (9)
– HCV identification and linkage to care among people who inject drugs (10)
– HCV testing and linkage to care at community health centers (7)
– Project ECHO sites (2)
– HCV testing and linkage to care in other settings (7)
Continued in FY2013 through Secretary Transfer
PCSI in Practice: Fully Integrated Screening for
HCV in an STI Clinic
March 11, 2014
Viral Hepatitis Testing Initiative Webinar
Alia Al-Tayyib, PhD and Laura Ginnett, MNM
Testing Site
Denver Metro Health Clinic
Largest STI clinic and HIV testing facility in Rocky Mountain region with
approximately 18,000 visits annually
Free and confidential STI, HIV, and HCV testing, counseling, and treatment
(sliding fee scale implemented January 2014)
Family planning services (Title X clinic)
Immunization services (HPV, HBV, HAV)
Established HIV Linkage to Care program (LTC)
Electronic medical record system (HealthDoc®)
Operates using a physician extender model: employs an 12-person clinical
staff and a 3-person clerical staff, supervised by a nurse manager and clinic
administrator, with daily medical activities supervised by one of 7 attending
physicians
Clinic housed within Denver Public Health, part of Denver Health
and Hospital Authority
Testing Protocol
1. During triage, all patients are asked a standard set of questions
related to HCV risk
2. If a patient has any risk factors, they are offered a free HCV rapid
antibody test
3. If the patient agrees to testing, two purple top tubes of blood are
drawn (similar to HIV protocol)
4. The patient then sees a provider for their clinic visit. During the
visit, the provider discusses the patient’s risk factors and delivers
the HCV rapid test results to the patient
5. If the patient has a non-reactive rapid result, their visit concludes
6. If the patient has a reactive rapid result:
A Linkage to Care counselor is paged to meet with the patient
A blood specimen is processed for quantitative RNA testing at the Denver
Health Microbiology Lab
HCV Screening Questions
Screening Tracking
Testing Outcomes
# of persons with HCV antibody result 2,857
# of persons with documented risk factor 2,491 (87%)
# of persons with documented counseling 1,326 (46%)
# of persons with positive HCV antibody 58 (2%)
# of persons with HCV RNA result 54 (93%)
# of persons with positive HCV RNA 32 (59%)
Denver Metro Health Clinic, January 1 - December 31, 2013
Demographics by HCV antibody status
Total n (%)
HCV Anti- n (%)
HCV Anti+ n (%)
X2 p-value
Gender
Male 2,068 (72) 2,041 (73) 27 (47) <0.001
Female 789 (28) 758 (27) 31 (53)
Race/ethnicity
White, non-Hispanic 1,280 (45) 1,259 (45) 21 (36) 0.665
Black, non-Hispanic 507 (18) 495 (18) 12 (21)
Hispanic 873 (30) 854 (31) 19 (33)
Other/unknown 197 (7) 191 (7) 6 (10)
Health insurance
Uninsured 2,486 (87) 2,441 (87) 45 (78) 0.051
Public 349 (12) 336 (12) 13 (22)
Private 16 (0.6) 16 (0.6) 0
Risk Factors by HCV antibody status
Total n (%)
HCV Anti- n (%)
HCV Anti+ n (%)
X2 p-value
Born 1945-1965 536 (19) 503 (18) 33 (57) <0.001
Ever injected 140 (5) 116 (4) 24 (44) <0.001
Shared intranasal supplies 713 (27) 692 (26) 21 (38) 0.051
Unprofessional tattoo 597 (23) 580 (22) 17 (31) 0.140
HCV+ sex partner 81 (3) 71 (3) 10 (20) <0.001
MSM activity 822 (29) 818 (29) 4 (7) <0.001
HCV Linkage to Care
Leverage existing HIV LTC program
Staffed by 2.5 FTE, supervised by a LCSW
One person on-call during business hours
24 hour voice mail, calls returned next business day
All patients with a reactive HCV rapid test are offered a
meeting with an LTC counselor
LTC counselors meet with patients and provide them with
education about hepatitis C, ways to prevent the spread of
hepatitis C, ways to live with hepatitis C, and treatment options
for hepatitis C
LTC counselors schedule a follow-up phone call or meeting
with patients to deliver HCV RNA results and referral
information
HCV LTC cascade from DMHC
52/53
Green lines denote CDC benchmarks
51/53 32/52 21/32 19/32
Lessons Learned
Obtaining buy-in from clinic staff is critical
Drawing blood for HCV RNA at initial visit very helpful
Leveraging existing HIV linkage program is efficient way to
provide linkage services for HCV positive clients
Limited access to primary care providers creates difficulty for
linkage
Follow-up with STI clinic patients can be challenging
Screening in STI clinic provides opportunity for HCV education
and counseling for at-risk persons
Acknowledgements
Prevention and Public Health Fund (1U51PS003805-01)
and CDC grants (3U51PS003805-01W1)
Denver Metro Health Clinic and LTC staff
Jeffrey Eggert Suzie Hunt-Fraizer
Melissa Edel Elizabeth Sanchez
Julia Weise Leslie Sotelo
Berlissa Abel Arley Tarin-Gonzalez
Anthony Abeyta Michael Fuhriman
Deborah Bell Alex Delgado
Pamela Berg Roberto Esquivel
Jessica Cabrera Maria Velesco
Kari Ehmann Diana Roble Madera
Valeria Escalera Tatiana Shimchenok
Lynn Hoskins Molly Weber
Questions?
Principal Investigator
Alia Al-Tayyib
303-602-3601
Project Coordinator
Laura Ginnett
303-602-3609
High Hepatitis C Infection Rate in Birth
Cohort Testing of an Urban, Primary Care
Clinic Population
Dawn Fishbein, MD
MedStar Washington Hospital Center MedStar Health Research Institute NASTAD Webinar March 11, 2014
CDC and USPSTF (B) recommend that all persons born between 1945-1965 (“Birth Cohort”) be tested HCV infection at least once. 27% of population, 81% of all HCV US infection; 73% of HCV related mortality 3.25% prevalence rate in this age group, five times higher than among adults
born in other years 8% AA men 45% do not report any risk factors 31.5% do not have health insurance Alcohol use: 57% who drink, moderate to heavy
HCV in US populations are 3x > HIV
Washington, DC (DC) has reported rates of 2% for HCV and 2.6% for HIV.
We hypothesized that HCV testing in a large, urban primary care clinic, regardless of ascertainment of risk factors, will reveal higher rates than those previously published in DC and in the US.
Background
MMWR, Aug 2012, Vol 61 (4)
Source: WHO
HCV – Global Distribution
December 2012, established HCV testing in the Primary Care Clinic at MedStar Washington Hospital Center, with CDC grant funding (HepTLC).
The aim was to sequentially test in the Birth Cohort, link directly to care with ID or GI, and create a sustainable testing program.
Eligibility:
born between 1945-1965
without predetermined risk factors in the electronic medical record
not previously HCV tested or positive.
HCV antibody positive patients were linked to care regardless of RNA status to receive either further testing and evaluation, or if RNA negative, health education and counseling.
Data are reflected for testing through February 14, 2014.
Methods
Tested
Birth
Cohort
Total
HCV Ab+
Intragroup
HCV Ab+
(n=1412)
(%)
(n=116)
(%)
116/1412
(8.2%)
Mean Age +
SD 58.7 + 5.7 60.0 + 4.9
Gender
Men 485 (34.4)
66
(56.9)
66/485 (13.6)
Women 927 (65.7)
50
(43.1)
50/927 (5.4)
Race/
Ethnicity
Black or
African
American
1237
(87.6) 107 (92.2)
B/A
A
Men
4
1
1
(
3
3
.
2
)
5
8
(
5
4.
2
)
58/411 (14.1)
B/A
A
Wo
men
8
2
6
(
6
6
.
8
)
4
9
(
4
5.
8
)
49/826 (5.9)
White,
non-
Hispanic
105
(7.4)
3
(2.6)
3/105
(2.9)
American
Indian or
Alaskan
Native
19
(1.4)
3
(2.6)
3/19
(15.8)
Asian
16
(1.1)
2
(1.7)
2/16
(12.5)
Insurance
Public 844 (59.8)
87
(75.0)
87/844 (10.3)
Private 568 (40.2)
29
(25.0)
29/568 (5.1)
Weekly reporting Input Provider popups in EMR
Patient presents to PCC Seen by MD
Venipuncture; counseling & literature provided
Anti-HCV Ab - : results by Provider/testing team
Anti-HCV Ab + and
RNA+ (Linkage)
Pt counseled on result given expedited appt to
Hepatitis Clinic for evaluation
Orasure rapid testing (fingerstick); counseling &
literature provided
Orasure + (Linkage)
Confirmatory RNA sent same day
Pt counseled on result given expedited appt to
Hepatitis Clinic for evaluation
Orasure - : Results provided and pt counseled on harm
reduction
Weekly reporting Input Provider popups in EMR
Patient presents to PCC Seen by MD
Venipuncture; counseling & literature
provided
Anti-HCV Ab - : results by Provider/testing
team
Anti-HCV Ab + and/or
RNA+ (Linkage)
Pt counseled on result given expedited appt to
Hepatitis Clinic for evaluation
Orasure rapid testing (fingerstick); counseling
& literature provided
Orasure + (Linkage)
Confirmatory RNA sent same day
Pt counseled on result given expedited appt to
Hepatitis Clinic for evaluation Orasure - : Results
provided and pt counseled on harm
reduction
Methods
Total Flagged n=5497 (%)
Total Tested 1412 (25.7)
Total Positive 116 (8.2)
*Linked to Care 99 (85.3)
**Seen at Appointment
80 (80.8)
Missed (not tested) 1442 (26.2)
Canceled & No Show
2643 (48.1)
HCV RNA+ 57 (71.3)
*Number of patient appointments with either Infectious Disease or Gastroenterologist,
regardless of RNA status
**Number of HCV Ab+ patients seen by both Infectious Disease and Gastroenterology
Total Flagged n=5497 (%)
Total Tested 1412 (25.7)
Total Positive 116 (8.2)
*Linked to Care 99 (85.3)
**Seen at Appointment 80 (80.8)
Missed (not tested) 1442 (26.2)
Canceled & No Show 2643 (48.1)
HCV RNA+ 57(71.3)
Total Flagged n=5497 (%)
Total Tested 1412 (25.7)
Total Positive 116 (8.2)
*Linked to Care 99 (85.3)
**Seen at Appointment 80 (80.8)
Missed (not tested) 1442 (26.2)
Canceled & No Show 2643 (48.1)
HCV RNA+ 57(71.3)
Rapid Test
146 (10.3)
Venipuncture
1266 (89.7)
Results
Results
In those HCV Ab+, 34.5% reported a history of IVDU at first appointment with a specialist.
Those infected were more likely to be men (OR 2.8 [CI95 1.8-4.1]) and persons with public insurance (OR 2.1[CI95 1.4-3.3]) than in those un-infected.
Approximately 88% of those tested and 92% of those HCV Ab+ were black/African American.
13.6% of all men tested were HCV Ab+; 11.9% were both HCV Ab+ and b/AA.
Of all b/AA men tested, 14.1% were HCV Ab+; > 8% reported by the CDC (p<0.001).
The first appointment adherence rate for those HCV infected was 80.8% compared to an overall primary care clinic appointment adherence rate of 52.1%.
Conclusions HCV prevalence rate of 8.2% is greater than:
CDC rate of 3.25% in the Birth Cohort (p<0.001)
Reported rate of 2% in the District of Columbia (p<0.001).
Since inception of the grant, rates have ranged between 7.8% – 10.0%.
Limitations:
Data and risk factors are collected from the EMR which often contains incomplete information. Thus, risk-factor comparisons cannot be made between those infected and not infected in this Birth Cohort testing.
As this population was largely b/AA, comparative conclusions cannot be drawn regarding race. However, these rates are very high in the b/AA community, especially amongst b/AA men and need further evaluation and attention.
In comparison to HCV rates amounting to 14.1% in b/AA men at this center, HIV rates in DC at the end of 2011 were reported at 5.4% in b/AA men.
These alarming statistics highlight the need to engage more men into harm reduction, transmission reduction and medical care.
Conclusions
These high prevalence rates of 8.2% and 14.1% are for patients already in care; rates would likely be higher for those not.
Sustainability needs: Utilizing veni-puncture for testing, which is covered by insurance.
Need to address missed testing opportunities as rates were equivalent to those tested.
Care navigation and education
Testing initiatives need to become standard of care and maintained as sustainable models. Need to empower patients to start to request testing
Patients are starting to speak about marketing efforts
Future Plans
Addressing Missed Opportunities Monthly resident reminders
Monthly email update
Letters and phone calls to empower patients who were “missed opportunities”
Emergency Department Testing
Surgical Testing
MedStar-wide testing
More grant writing to address the entire Cascade of Care ….. Industry and Foundation service grants
PCORI
NIH
CDC ….
Acknowledgements
HCV Testing Team:
Alex Geboy
Allison Daly
Candice Sewell
Sandeep Mahajan
Carmella Cole
Primary Care Clinic
Others: Tracey Gantt, Leslie Ruhno
• Funding: CDC-RFA-PS12-1209PPHF Category B, Part 3
BFree Columbus
Columbus, Ohio
March 11, 2014
Prepared by Manju Sankarappa, Executive Director
Preetam Bekal, Program Coordinator
To work toward sustaining long term approaches to the promotion of
health and wellness through strong partnerships that empower AAPI
individuals, families, and communities.
Voluntary group – six founding CBOs
501(c)(3) pending
Listserv (yahoo group)
Organized bi-annual Ohio Asian Health Conference
Health Through Action Grant
Informal workgroups
Tobacco Control
Hepatitis B
Domestic Violence/Mental Health
Special Priorities – Statewide Needs Assessment
National Health Through Action Initiative
Be the catalyst to improve health of the local Pan-Asian Community
Why Hepatitis B is important •High Prevalence –Worldwide:
•2 billion exposed
•400 million chronically infected
•1,000,000 deaths/year
•Approximately 2 people die each minute from Hepatitis B – U.S.
•12 million exposed
•1.3+ million chronically infected
•4,000 deaths/year
•Effective vaccination exists and
“Hepatitis B is a Serious Preventable Disease”
• Columbus ranks 8th highest in U.S. with foreign-born Asian and African population
Program Coordinator Preetam Bekal, M.D
DDE
Program Manager African Hassan Omar
Project Director Manju Sankarappa
Phlebotomist Wynette
Community Health Advocates Qodah, Muna, Lucky, Yusuf, Mursal, Ayan, Lisa, Ahmed,
Community Health Advocates HuangWei , Robert, Kosal,
Daniel, June, Carmen, Suzanne
Program Manager Asian Nancy Pyon, Chin-Yinh Shih
Office Assistant Georgie Cline
DDE
Tina, James, Kelye, James, LaDonte
B f r e e Te a m
Overview
Bfree Columbus Prevention Activities
• Building Relationship with Community
• Building Relationship with Providers
• Building Relationship with Diverse Organizations
• Selecting the Team Members that Team players
• Training the team
• Disseminate the Grant information operation plan
Education
• Providing Objectives and Goals and Deliverables of the project
• Preparing all the necessary document for CHA’s
• Training the Program Managers and Community Health Advocates
– Nurse/Educator - Two day total 6 hour training for each Team Member
– Measuring the knowledgebase using Pre- and Post test tool
Testing Sites
Clinics
African
Community
Event
Asian
Community
Events
Asian Health
Initiative(OSU
Free Clinic)
Noor Clinic
(OSU Free
Clinic)
Heart of Ohio
Health
Centers
Community Events
• African Community Events
• Asian Community Events
Community Events
Chinese Festival
Helen’s Asia Kitchen
Ethiopian Community Center
Minority Health Month
Gurudwara – Sikh Community
Nepalese/Bhutanese Community Event
Asian American Community Services
Gracepoint Sanctuary
Asian Festival May 24th and 25th
Somali Community Association of Ohio -
Global Mall
Tamaya Masjid
Minority Health Month Health Fair,
Ghana Church Etheopean community
Testing activities
• Community Events
• Free Clinics
• Health Fairs
• Festivals
• Faith-based organizations
Site locations
• Somali Community Association of Ohio
• Global Mall
• Asian Health Fair
• Noor Community Center
• Helen’s Kitchen Restaurant
• Rardin Family Clinic – Asian and Noor Clinic
• City of Columbus Adventure Center
Partnerships
• Ohio Department of Health • Franklin County Public Health • Columbus Public Health • Columbus Neighborhood Health Center • Franklin County Public Health • OSU Wexner Medical Center – Free Clinics • Ohio Health Gastroenterology Group • Asian American Physicians of Indian Origin • Community Based Organizations –AACS, ACSC, AFC, SCAO, LMAA,
FIACO etc • Faith-based organizations – Gurudwara, Noor Community Center,
Cambodian Temple, Lao Temple, Gracepoint Sanctuary and more
Vaccination/Treatment -
Counseling and Referral
Collaborative Services for “B Free Columbus”
# of community events with HBV testing
Translation materials for Foreign-born participants, i.e., posters, pamphlets
Being developed as needed, have received material for Asian languages
Posters, Flyers, Banner.
Distributed in local community gathering places
Language specific liaisons
Bhutanese/Nepalese, Chinese, Cambodian, Hindi, Lao, Tagalog, Vietnamese,
Somali, Ghanaian, Ethiopian, Eritrean, Swahili
CDC’s Programmatic Updates
E-Authentication
Done
Site Identifications
Guidelines are set and in implementation
Evaluation Webinar
Attended by Preetam Bekal and Manju Sankarappa
Data collection
Program Managers and BFree Team consisting of 20
people
Case reporting
Preetam and Manju Sankarappa
Cora Munoz and Jennifer Kue
Stakeholders/Partners o Collaboration with Ohio Department of Health – Kathleen Koechlin
o Local health department – Denice Abbot, Virginia Brendenmuth
o Franklin County Public Health – Radhika Iyer
o Linkage to Care (medical facilities, FQHC, other providers)
o Ohio Gastroenterology Group
o OSU Hepatology group Free Clinics – OSU Free Clinics – Rardin Family Practice
o Asian Health Initiative, Noor Clinic
o Heart of Ohio Health clinics
o Capital Park, Whitehall Clinic
o Columbus Neighborhood Health Center
o Columbus Public Health – Vaccination –(Free for Underinsured and Uninsured)
o Lab services – OhioHealth, Ohio State University Labs, Mt. Carmel Labs
o Physicians on Record - Foreign-born African – Dr. Mohamed Hashi
o - Foreign-born Asian – Dr. John O’Handley
o - Foreign-born Asian – Dr. Angel Villanueva
o - Dr. Jagdish Urs – Nationwide Children’s Hospital - Dr. Bernard MOA, letter of support, MOU documenting support
o Training Activities to private providers – ODH Director has already begun the Process
o Posters are placed in Physician’ office
Screening
• Held at least seven Hepatitis B screenings in Columbus • Results: 7.63% positive 8.89% in Foreign-born African
Community Non PPHF funding results 6.73% • After the screening, the participants receive: • 1. Personal counseling, if positive; Letter describing
results • 2. Community Health Advocate will contact • 3. Translated brochures • 4. Gift cards after screening • 5. Available resources for follow-up and vaccines
Screening Analysis
Population by Gender
Female 827
Male 920
Total Data
PPHF – 1568, Positive - 107
Non-PPHF 467 Positive - 22
Number Countries represented 58
Number of of screenings
36 screenings
Added more permanent site on weekends
Challenge:
Collecting correct address
Followups
Resources
• Be familiar with what resources are
available right here in Columbus
• Vaccinations are available at the Columbus Health Department
• Screenings available at:
• Bfree Columbus Health screenings- visit website for date and time: www.oahcoalition.org
• Linkage to Care provided by BFree Columbus
• Contact phone number – 614-366-8214 or e-mail [email protected]
Columbus Neighborhood Health Center, Heart of Ohio
Health Centers
Primary Care Physician
*Free clinics
*FQHC
Linkage to Care For Positive Hepatitis B
Linkage to Care For Positive
Hepatitis B
Underinsured/Ininsure
d
Uninsured
PCMH
Insured or able to payout of
Gastrenterology/ Hepatology
Monitors Liver function
tests/virus load
Asian Health Initiative, Noor Clinic,
Columbus Public Health
Treatment of Patients using
proper protocalls
Comments/Questions/Answers
“Hepatitis B is a Serious Preventable Disease”
For More Information Contact:
Oscar Mairena
Manager
Viral Hepatitis/Policy & Legislative Affairs
NASTAD
(202) 434-8058