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Hepatitis C and Innovative Public Health Practice

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**). 8%. Overall prevalence 1.6% 2.7 million Americans chronically infected

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Hepatitis C and Innovative Public Health Practice

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  1. Hepatitis C and Innovative Public Health Practice Ann Thomas MD, MPH Ann Shindo, PhD, MSW, MPH, MS Oregon Public Health Division

  2. Prevalence of Anti-HCV* (US,1999–2002 NHANES**) 8% • Overall prevalence 1.6% • 2.7 million Americans chronically infected • 48,000 Oregonians chronically infected 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 2006;144:705-714

  3. Estimated Incidence of Acute HCV (US, 1982–1993) 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 1987 1989 1993 1985 1991 Source: CDC Sentinel Counties Study of Acute Viral Hepatitis

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

  5. HCV: Clinical Features • Incubation period: Virus detectable 1–2 weeks Antibodies 7–8 weeks • Clinical illness:30–40% • Jaundice20–30% • Anorexia, malaise,10–20%or abdominal pain • Typical course:Asymptomatic for decades

  6. 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

  7. Risk of Fatal Outcome in Persons Who Develop Hepatitis C Infection 48,000 Oregonians Time 100 10,000 85% Chronic85 15% 20% 1,000–2,000 Cirrhosis17 80% Resolve15 25% 75% Mortality4 Stable68 Stable13 Courtesy of Seeff, LB and Alter, HJ.s

  8. 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 Costs of HCV Source: Leigh Arch Int Med 2001, 161:2231–2237; Oregon DHS OMAP, personal communication

  9. Reported Risk Factors for Acute HCV Infection, Oregon, 2006–2007, n = 47 Other** High Risk Sex 5% 10% Unknown 22% 63% PWID* *PWID: Persons Who Inject Drugs **Other: Tattoo, pierced, employed in medical field

  10. 100 80 60 40 20 0 0 6 12 18 24 30 36 42 48 54 60 66 72 Risk of HCV, HBV,* and HIV Infection Among Persons Who Inject Drugs (PWID) Baltimore 1983–1988 HCV HBV Seroprevalence (%) HIV Duration of Injecting (mo) * Hepatitis B Virus Garfein RS. Am J Public Health. 1996;86:655.

  11. 70 60 50 40 Percent 30 20 10 0 Hep C HIV Hepatitis C and HIV in Persons Who Inject Drugs, Oregon State Penitentiary, 1998 Source: Public Health Division, Oregon DHS

  12. Prevalence of HCV, HBV, and HIV in Persons Dying of Injection Drug Overdose* Number Positive/ Number Tested Percent *Oregon, Nov. 1999–Dec. 2001 Source: Public Health Division, Oregon DHS

  13. Prevalence of HCV • Overall, 317/936 (32%) persons tested were HCV+ • Most important risk factor identified was injection drug use 60 50 40 Percent (%) Positive 30 20 10 0 Overall PWID Multnomah County Screening Program, 2000 Source: Public Health Division, Oregon DHS

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

  15. Click on the down arrow if you can’t see the response choices. Question Prevalence of hepatitis C among Persons Who Inject Drugs (PWID) is higher outside the Portland-Metropolitan area: A. True B. False

  16. 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% Multnomah County HCV Registry Study, 2005–2006 *Except if patient is seen in ED, inpatient, occupational health, blood bank, or outreach

  17. Education 50% with > high school education Income 80% < $30,000 Homeless 25% homeless in past year Insurance 37% with Medicaid 24% uninsured Demographic Characteristics of Enrolled Subjects, n = 196

  18. 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 Addiction Issues

  19. 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 Mental Health Issues

  20. 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 2007–2008Pilot HCV Seroprevalence Activities

  21. 45 Men 40 Women 35 30 25 Number of cases 20 15 10 5 0 0-19 20s 30s 40 and up Age group Sex and Age Among HCV Positive Cases, n = 124

  22. Race Among Anti-HCV Positive Cases, n = 128 Mixed 2% Black 2% Asian 1% Unknown American Indian/ 5% Alaska Native 6% 84% White

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

  24. Prevalence of HCV Among PWID in Oregon, 2007 NEX* * Needle Exchange

  25. 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

  26. Federal picture State picture Innovative program example More we can do? HCV Innovations

  27. 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

  28. National Center for HIV, Hepatitis, STD, TB Prevention (NCHHSTP) Program Collaboration Service Integration (PCSI) HCV and Public Health Interventions: Federal Focus

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

  30. 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

  31. 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! PCSI Bottom Line

  32. 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 HCV and Public Health Interventions: State Focus

  33. 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 Innovative Approaches Example: Marion County, Oregon

  34. 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 Outcomes

  35. 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 Supports to Integrated Service Delivery

  36. 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) Barriers to Integrated Service Delivery

  37. 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 Innovative Approaches Example: HIV Alliance, Eugene, Oregon

  38. 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) Feasibility of PCSI in Oregon Local Health Departments

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

  40. Micro • Mental health • Substance use • Social support • Macro • Stigma • Health policies • Federal funding streams • Meso • Housing • CAM • A/B vaccines HCV + Individual Seeking Treatment Drug-Based Therapies Barriers to Medical Intervention Barriers

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