challenges facing communities combating hepatitis c dr. virginia a. caine, m.d. director, marion...
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Challenges Facing Communities Combating
Hepatitis C
Dr. Virginia A. Caine, M.D. Director, Marion County Public Health DepartmentAssociate Professor of Medicine, Division of Infectious Diseases,Indiana University School of MedicineChair, Infectious Diseases Section, National Medical Association
Acute vs. Chronic
Acute Chronic
Clinical Illness
Short term illness that occurs within the first six months after exposure to the virus.
Long term illness that occurs as the virus remains in the body.
Progression
Usually progresses to chronic infection.
Sequelae include cirrhosis, liver cancer and death.
Association
Acute cases seen with increasing IVDU.
Blood transfusions, IVDU, sex
Scott County pop. 24,000; Austin, IN pop. 4,200ott County Indiana HIV outbreak: geographic distributionpop. 4,200
Scott County: Among the state’s 92 counties, ranked 92nd in a variety of health and social indicators, including life expectancy
Demographics of HIV-infected cases (N=135)
Median age 32 years, range 18-57 45% female 55% male 100% non-Hispanic white Of 112 interviewed, 108 (96%) injected drugs
All oxymorphone, some methamphetamine and heroin as well
High poverty (19.0%) and unemployment (8.9%) Low educational attainment (21.3% no high school) High proportion without health insurance
Early Release, MMWR Morb Mortal Wkly Report 2015, April 24, 2015; U.S. Census http://quickfacts.census.gov/qfd/states/18/18143.html
Use among of HIV-infected cases (N=108)
Multigenerational Sharing of injection equipment common Daily injections: 4-15 Number of partners: 1-6 per injection event
Early Release, MMWR Morb Mortal Wkly Report 2015, April 24, 2015
Hepatitis C Infections
Convenience sample of specimens tested from high-risk persons (e.g., injection-equipment sharing or sexual partners)
HIV-infected 95% HCV co-infected At-risk persons est. 60% HCV monoinfected
Case Counts for Marion County, IN
2010 2011 2012 2013 2014
Acute
Chronic
Acute
Chronic
Acute
Chronic
Acute
Chronic
Acute
Chronic
Females 1-4 350 5 325 1-4 359 1-4 367 13 315
Males 1-4 555 1-4 571 6 616 1-4 485 7 456
Trans-gender
1-4 1-4 1-4
Unknown 1-4
Hepatitis C in Marion County, IN New chronic hepatitis C cases among females have remained steady during 2010-2014; whereas chronic cases among males has somewhat decreased during the past two years.
Acute hepatitis C cases in the female population saw about a 3-fold increase from 2013 to 2014; a smaller increase was realized among males.
2015 Data, Marion County, IN
Gender Acute Chronic
Male 5 405
Female 7 336
These numbers suggest 2015 hepatitis C numbers will surpass the numbers from 2014.
Ages of Hepatitis C Acute Cases2009-2014, Marion County, Indiana
Hepatitis C, Drug Use, Overdose Deaths Drug overdose deaths utilized as a secondary indicator
Marion County Rate (18.4/100,000) is 25% higher than Indiana’s Rate (14.85/100,000)
Males more likely to die from overdose death
Female overdose death increased from 60 in 2010 to 80 in 2014
Hepatitis C, Drug Use, Non-Fatal Overdoses Non-fatal opioid overdoses in Marion County are higher than Indiana Marion County: 38.14 per 100,000 Indiana: 27.97 per 100,000
Females are hospitalized at a higher rate than males
Hospitalizations due to overdose steadily declining from 64,000 in 2009 to 60,000 in 2013
Indiana Hepatitis C Reporting Rule
http://www.in.gov/isdh/files/comm_dis_rule(1).pdf
Who What When Where
Provider
Acute Within 5 Days
Local Health Dept.
Laboratory
Acute and
Chronic
Within 7 Days
Local Health Dept.
Hospital
Acute Within 5 Days
Local Health Dept.
Chronic HCV Data: Surrounding States and Similar Cities
City/County Chronic HCV Incidence
Year Reported
Chicago/Cook 3531 2013
Indianapolis/Marion County
883 2014
Columbus/Franklin
Not reported Not reported
Cincinnati/Hamilton
Not reported Not reported
Nashville/Davidson
Not reported Not reported
Cleveland/Cuyahoga
Not reported Not reported
Louisville/Jefferson
Not reported Not reported
Gaps in Hep. C Reporting 70 to 80% of people with Acute Hep. C do not develop symptoms
Testing recommendations focus on baby-boomers Providers generally follow these guidelines, excluding younger people from testing
Reporting rules only require providers to conduct case history and report acute cases
A significant number of acute and chronic cases of Hep. In young people missed because of discrepancy between guidelines and disease symptoms
CDC Fact Sheet (May 31, 2015), http://www.cdc.gov/hepatitis/hcv/cfaq.htm
CDC’s Recommendations of Whom Should be Tested? Anyone Born from 1945 through 1965 Have received blood products with clotting factor before 1987
Have received blood transfusion or organ transplant before July 1992
Have ever injected drugs, even if only one time Have HIV Have been on kidney dialysis for several years Are health or public safety workers who have been stuck with a needle or other sharp object with blood
Born to mother with hepatitis C
Case History Helps Develop Control Measures for Hepatitis C1. Investigation by the local health officer shall be performed within five (5) business days for the purpose of determining risk factors for infection and obtaining contacts.
Contacts are defined as sexual partners, household members, individuals with whom needles have been shared, and others who have been exposed to infectious body fluids.
Case History
Investigation shall focus on a history of the following: Surgery Transfusion or other blood products exposures.
Hemodialysis. Employment as a health care worker. Other contacts with blood or other potentially infectious materials during the incubation period.
Main Reporter: Electronic lab reportsAnalysis of Hepatitis C (acute and chronic) reports received during a 6 month period
Labs only, 988
Providers,70
Both, 78
*1 had neither of those records (report originated from another public health dept.)
Lab Reporting Lacks Case History Ability Labs usually do not receive name of patient for whom running test Not required to receive such information
If receive a positive test, report positive to LHD and provider Without personal identifying information, LHD can’t conduct case history
Providers generally unable to locate patient because of transient nature of intravenous drug users
National Counts of Reports
Hepatitis C Virus (HCV)2005 2006 2007 2008 2009 2010 2011 2012 2013694 802 849 878 781 853 1,23
01,778
2,138
Estimated Actual New Cases ofHCV (range)
2011 (estimated)*
2012 (estimated)*
2013 (estimated)*
16,500 (7,200-43,400)
24,700 (19,600-84,400)
29,700 (23,500-101,400)
* Actual acute cases estimated to be 13.9 times the number of reported cases in any year
Source: http://www.cdc.gov/hepatitis/hbv/statisticshbv.htm#section4
Gaps in Care
Majority of States Medicaid programs only allow a specialty provider to treat and get reimbursed for treatment
Sofosbuvir, an effective medicine, considered a “non-preferred” drug, which requires medical necessity to be provided to patient Medical necessity: liver fibrosis score of F3, or F4
Liver fibrosis precursor to cirrhosis or cancer
Higher score, more liver fibrosis
F Scores Across the States
F1F2F3F4NoneUnknown
Impact on Women:
Women generally overlooked when developing interventions
Lack of women-focused services for treatment and prevention
More likely to lack access to care, let alone a specialized treatment
Older women are more likely to develop fibrosis and are less responsive than younger women to pegylated interferon and ribavirin
Jenny Iversen, et. al., JAIDS 69:pS176-S181 (2015). Kaiser Family Foundation, Health Reform: Implications for Women's Access to Coverage and Care (2013). Mary Jane Burton, et. al., South Med J. 2013;106(7):422-426.
Impact on Women:
Women of childbearing age have higher rates of sustained virologic response, but current therapies are contraindicated during pregnancy
Vertical transmission of hepatitis C virus occurs, but data supporting recommendations for prevention of mother-to-infant transmission are limited Approximately 1 in 20 chance mother passes it to child
Hepatitis in Pregnancy, Paediatr Child Health. 2008 Jul; 13(6): 535.
