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Challenges Facing Communities Combating Hepatitis C

Challenges Facing Communities Combating Hepatitis C. Dr. Virginia A. Caine, M.D. Director, Marion County Public Health Department Associate Professor of Medicine, Division of Infectious Diseases, Indiana University School of Medicine

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Challenges Facing Communities Combating Hepatitis C

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  1. Challenges Facing Communities Combating Hepatitis C Dr. Virginia A. Caine, M.D. Director, Marion County Public Health Department Associate Professor of Medicine, Division of Infectious Diseases, Indiana University School of Medicine Chair, Infectious Diseases Section, National Medical Association

  2. Acute vs. Chronic

  3. 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

  4. 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

  5. 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

  6. 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

  7. Case Counts for Marion County, IN

  8. 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.

  9. 2015 Data, Marion County, IN These numbers suggest 2015 hepatitis C numbers will surpass the numbers from 2014.

  10. Ages of Hepatitis C Acute Cases2009-2014, Marion County, Indiana

  11. 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

  12. 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

  13. Indiana Hepatitis C Reporting Rule http://www.in.gov/isdh/files/comm_dis_rule(1).pdf

  14. Chronic HCV Data: Surrounding States and Similar Cities

  15. 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

  16. 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

  17. Case History Helps Develop Control Measures for Hepatitis C 1. 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.

  18. 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.

  19. 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.)

  20. 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

  21. National Counts of Reports * 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

  22. 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

  23. F Scores Across the States F1 F2 F3 F4 None Unknown

  24. 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.

  25. 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.

  26. Questions? Virginia A. Caine, M.D. 317-221-2301 vcaine@marionhealth.org

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