Hepatitis C and Innovative Public Health Practice

1
Hepatitis C and Innovative Public Health Practice

• Ann Thomas MD, MPH
• Ann Shindo, PhD, MSW, MPH, MS
• Oregon Public Health Division

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Prevalence of Anti-HCV (US,19992002 NHANES)

• Overall prevalence 1.6
• 2.7 million Americans chronically infected
• 48,000 Oregonians chronically infected

8
7
Men
Women
6
5
4
Prevalence of anti-HCV
3
2
1
0
Hepatitis C Virus National Health and
Nutrition Examination Survey
All
6-19
20-34
35-39
40-44
45-49
50-54
55
Age Group (years)
Source Armstrong Ann Intern Med 2006144705-714
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Estimated Incidence of Acute HCV (US, 19821993)
25
Surrogate testing of blood donors
Anti-HCV test (first generation) licensed
20
15
Cases per 100,000
Anti-HCV test (second generation) licensed
10
5

0
1983
1985
1987
1989
1993
1991
Source CDC Sentinel Counties Study of Acute
Viral Hepatitis
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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
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HCV Clinical Features

• Incubation period Virus detectable 12
  weeks Antibodies 78 weeks
• Clinical illness 3040
• Jaundice 2030
• Anorexia, malaise, 1020or abdominal pain
• Typical course Asymptomatic for decades

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Risk of Fatal Outcome in Persons Who Develop
Hepatitis C Infection
Time
100
85
Chronic85
15
20
Cirrhosis17
80
Resolve15
25
75
Mortality4
Stable68
Stable13
Courtesy of Seeff, LB and Alter, HJ.s
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Risk of Fatal Outcome in Persons Who Develop
Hepatitis C Infection
48,000 Oregonians
Time
100
10,000
85
Chronic85
15
20
1,0002,000
Cirrhosis17
80
Resolve15
25
75
Mortality4
Stable68
Stable13
Courtesy of Seeff, LB and Alter, HJ.s
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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
  20102020

• Oregon Medicaid fee-for-service patients (2007
  data)
• Medication costs400,000 (doesnt
  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, 16122312237
Oregon DHS OMAP, personal communication
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Reported Risk Factors for Acute HCV Infection,
Oregon, 20062007, n 47
Other
High Risk Sex
5
10
Unknown
22
63
PWID
PWID Persons Who Inject Drugs
Other Tattoo, pierced, employed in medical
field
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Risk of HCV, HBV, and HIV Infection Among
Persons Who Inject Drugs (PWID)
Baltimore 19831988
HCV
HBV
Seroprevalence ()
HIV
Duration of Injecting (mo)
Hepatitis B Virus
Garfein RS. Am J Public Health. 199686655.
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Hepatitis C and HIV in Persons Who Inject Drugs,
Oregon State Penitentiary, 1998
Source Public Health Division, Oregon DHS
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Prevalence of HCV, HBV, and HIV in Persons Dying
of Injection Drug Overdose
Percent
Number Positive/ Number Tested
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
Oregon, Nov. 1999Dec. 2001
Source Public Health Division, Oregon DHS
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Prevalence of HCV
60

• Overall, 317/936 (32) persons tested were HCV
• Most important risk factor identified was
  injection drug use

50
40
Percent () Positive
30
20
10
0
Overall
PWID
Multnomah County Screening Program, 2000
Source Public Health Division, Oregon DHS
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Prevalence of HCV in Different Risk GroupsAmong
Non-PWIDs
Sexually Transmitted Infections Men who have
sex with men
Source Multnomah County, 2000
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Question

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

A. True B. False
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Multnomah County HCV Registry Study, 20052006

• 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
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Demographic Characteristics of Enrolled Subjects,
n 196

• Education
• 50 with gt high school education
• Income
• 80 lt 30,000
• Homeless
• 25 homeless in past year
• Insurance
• 37 with Medicaid
• 24 uninsured

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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

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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

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20072008 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

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Sex and Age Among HCV Positive Cases, n 124
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Race Among Anti-HCV Positive Cases, n 128
Mixed
2
Black
2
Asian
1
Unknown
American Indian/
5
Alaska Native
6
White
84
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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
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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
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Summary

• 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

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HCV Innovations

• Federal picture
• State picture
• Innovative program example
• More we can do?

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Domestic HIV, Viral Hepatitis, STI, and TB
Prevention Appropriated Funds
Hepatitis
2
TB
Total 963.1 million
14
STD
16
68
Domestic HIV
Fiscal Year 2006 Source CDC
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HCV and Public Health Interventions Federal Focus

• National Center for HIV, Hepatitis, STD, TB
  Prevention (NCHHSTP)
• Program Collaboration Service Integration (PCSI)

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PCSI
http//www.cdc.gov/nchhstp/programintegration/docs
/PCSImeetingreportwithcover11-2620_2.pdf
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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
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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 its one word!

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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

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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

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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

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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

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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)

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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

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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)

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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!

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Barriers to Medical Intervention
Barriers