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SC DHEC Hepatitis C Surveillance, Testing & Counseling Pilot Projects, Hepatitis C Coalition

SC DHEC Hepatitis C Surveillance, Testing & Counseling Pilot Projects, Hepatitis C Coalition. CDC National Hepatitis Coordinators’ Conference San Antonio, Tx Jan. 2003.

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SC DHEC Hepatitis C Surveillance, Testing & Counseling Pilot Projects, Hepatitis C Coalition

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  1. SC DHEC Hepatitis C Surveillance, Testing & Counseling Pilot Projects,Hepatitis C Coalition CDC National HepatitisCoordinators’ ConferenceSan Antonio, Tx Jan. 2003 Robert Ball, MD, MPHInfec.Dis.-HIV-Hepatitis Consultant/EpidemiologistSC DHEC - Bureau of Disease ControlAssociate Director, USC S/M - Inf. Dis. Division

  2. SC DHEC Viral Surveillance ’01-’02 * HIV HCV Estimated chronic 16,000 - 20,000 50,000 - 70,000 disease burden (est. 4 of 5 PWHCV don’t know) Work burden ~ 20+/ wk ~ 130+/ wk (# of case reports) ~ 1000/ yr ~ 6700/ yr # Federal/ SC FTEs 12 0 * $ Federal/ SC resources > $ 500,000 0 * * Hep C Surveillance: .5 FTE (F. Foundation ’00  DHEC 0.5 GA ‘01) R. Ball, MD, MPH

  3. Chronic Hepatitis C Virus (HCV) Datain SC: Surveillance & Under-Reporting • CDC est. ~30-36 K new cases of hep C each year/ USA • If docs Dx & report SC’s %  ~ 400-500 new cases/ yr • All hep A, B, C, D, E, non A-E reporting is required • BUT: no IgM/ other confirmatory test for acute hep C • Acute hep C reports ‘96-’02: avg. only ~ 22 per year ! • Most reports are from labs: no demo/ clinical/ risk info • “Chronic” HCV >12 K cases (12/02), usu w/o race, risk • Limited demographic data (B:W~2:3 for chronic HCV) R. Ball, MD, MPH

  4. Chronic HCV cases reported to DHEC Registry 1/1/97–12/31/02 >12,601 M 67%, F 32% ~ 2:1 Report source: O-P lab = 60.5 % Age: 40-49 = 45.4 % Hosp lab = 16 % 50-59 = 20.6 % 30-39 = 18.4 % Risk: Not Reported = 97 % Race: Cau = 25.8 % Af-Am = 17.6 % < note 2:3 B:W ratio Not Rep = 56 % (lab reports) R. Ball, MD, MPH

  5. SC DHEC Hep. C CTRPN Pilot Projects * 2002: Hep C Counseling, Testing, Referral, & Partner Notification Pilot Projects: #1 (App III- Sp’burg) 2/02 #2 (Trident- Chas.) 5/02 #3 (Upp.Sav.-Gr’wood) 8/02 #4 (Lowcountry-Colleton) 9/02 ? ? * thru 12/02 #5 (PeeDee -Florence) 10/02 Testing $: $18 K DHEC/ ELC + $15 K DAODAS + $25 K Schering/Roche SC Dept Health Central Office (Columbia) R. Ball, MD, MPH

  6. Hepatitis C Counseling, Testing, Referral, & Partner Notification Pilot Projects 2002 • Integrated HCV C&T into existing STD, HIV, FP, Maternity, & TB services in 5 public health districts • On average, no more than 7 additional minutes to provide HCV education & counseling per Pt • Procedure: • History/ Risk Assessment • Assess for symptoms of hepatitis (rare) • Provide HCV education if risk factors • Offer HCV testing for those at risk • Obtain serum for HCV EIA & RIBA Ab/ bDNA Viral Load

  7. HCV Tests (~ to HIV Tests) • HCV EIA Antibody screen – may be false (+) • HCV RIBA Antibody confirmatory (~ W. Blot for HIV) • HCV bDNA – measures the virus, not antibody • - Qualitative (negative or positive) • - Quantitative (viral load, or # of HCV/ ml) • HCV PCR RNA – measures the virus, not antibody (DHEC BoL doesn’t perform any more) R. Ball, MD, MPH

  8. HCV Basic Education/Counseling • HCV infection and chronic liver disease • Transmission modes & risk factors • Free HCV testing available if at risk • Benefits of detecting infection early • Available curative medical treatments • What if test is positive – counseling & referral • Prevention messages • If (+), notify partner(s) & offer testing

  9. “Natural History” of HCV Infection * Time (15 - 30 yrs) 100 People 15-20 % Resolve(15) 80-85 % Chronic (80-85) Watch Progression more rapid if alcohol, HIV, hepatitis A/B, other co-factors present 80 %- 20-30 %+ “Stable” (68) Cirrhosis (17+) TREAT 75 % 25 %+ Stable ? (13) Mortality (4+) TREAT *Leading Cause of Chronic Liver Dis. & Indication for Liver Transplant MJ Alter (CDC), adapted from HJ Alter (NIH), modified by R Ball (SCDHEC)

  10. DHEC Hepatitis C Risk Assessment • More than 10 lifetime sex partners • Multiple episodes of STDs • Blood transfusion prior to July 1992 • Recipient of clotting factor before 1987 • Injecting drug use (prior or current) • Sex partner with risk factors or who is HCV+ • HIV positive • Born to mother who is HCV+ • Hemodialysis patient • Recipient of organ transplant before 7/ 92

  11. DHEC Adult Clinical Encounter Form HCV Risk Assessment HCV preval. & # of sex partners: > 50 ~ 9% 10-49 ~ 3% 2-9 ~ 2% R. Ball, MD, MPH

  12. HCV Test Results • Document on Clinical Encounter Form • Negative Results: May give results by phone. • Positive Results: Face-to-face encounter “preferable” • Explain results. Do not repeat tests unless medical consultation. • Provide info regarding HCV. • Offer Hepatitis A vaccination. • Offer Hepatitis B vaccination if risk factors (most patients eligible). • Counsel pt re: reducing risks of transmission. • Counsel pt re: ways to prevent further harm to liver. • Discuss partner(s) referral for testing. • Refer pt to PMD (ref: SC Hepatitis C Coalition’s SC Physicians Referral List, local physician resources)

  13. HCV Test Result Interpretation Clinical statusEIA AbRIBA AbbDNA • Has HCV (+) S/CO>3.8 (+) (+) > # • False (+) EIA (+) S/CO<3.8 (-) (-) • Had HCV, now (+) S/CO~3.8 (+) (-) cleared (15-20%) • Results pending (+) pending pending prob false (+) (+) S/CO<3.8 prob true (+) (+) S/CO>3.8 wait 1-2 wks R. Ball, MD, MPH

  14. DHEC Billing for Hepatitis C Testing • Bill as for STD tests/services (ie, to Central Office Hepatitis program) if from 5 Pilot Projects • May bill Medicaid for Hepatitis C test. (EIA is $10, no additional charge for RIBA, PCR.) • If charging on sliding fee scale, Hep C test may be incorporated into fee scale. • If charging flat fee for STD/HIV services, do not charge additional $10 for Hep C test. • 2003: EIA $10, RIBA $60, bDNA $ 120

  15. Public Health Service Guidelines for Counseling HCV-Positive Persons • HCV-positive persons should: • Be considered potentially infectious • Keep cuts and skin lesions covered • Be informed of the potential for sexual transmission • Be informed of the potential for perinatal transmission • no data (yet) to advise against pregnancy or breastfeeding • HCV-positive persons should be referred (medical care, support group, etc.) • HCV-positive persons should not: • Donate blood, organs, tissue, or semen • Share household articles (e.g., toothbrushes, razors)

  16. HCV : Testing, Treatment, Referrals • HCV testing ~ available (private & pu.he. providers) • Individual benefits of knowing one’s status: • Prevent further liver damage (ie, avoid alcohol) • Prevent transmission to others • Medical evaluation – curative therapy candidate ? • Tx: current combination medications can cure approx. 2/ 5 – 3/ 5 persons completing therapy R. Ball, MD, MPH

  17. Improved Cure Rates of HCV - 2001(~3 of 5 persons completing therapy) R. Ball, MD, MPH

  18. SC DHEC Hep. C CTRPN Pilot Projects Testing Results 6-12/02 : Summary • # health dep’t. clients counseled: est. > 5000 • # At-risk clients HCV tested: 1329 (~ 1 in 4) • # EIA (+): SCO>3.8/ all(+): 110 (86%)/ 128 (9.6%) • # confirmed HCV RIBA (+): 116 (8.7%), 12 indet. or (-) • # bDNA (+): 72 (5.4% of 1329) + 21 specimens^QNS  ~7% of 1329 likely (+) viral load (ie, current infection) • Clients “referred” for medical services: est. ~ 90% • Rate of acceptance by private physicians: est. ~ 50% ($) R. Ball, MD, MPH

  19. SC DHEC Hep. C CTRPN Pilot Projects • Hep C-specific C & T integrated into existing services • Risk Assessment in: STD, HIV, Prenatal, Fam.Plan. Cl. • Hep C testing encouraged for any person at risk • Hep C testing in DHEC Lab (funded via mult. sources) • 2003: Hep A & B vaccine availability for PWHCV • 2-12/02: > 1600 persons tested, ~150 (~9.4 %) EIA (+) • Liaison with private physicians for treatment, services • Staff enthusiastic, attempting a referral tracking system R. Ball, MD, MPH

  20. SC Hepatitis C Coalition (SC HCC) • Who? Health care professionals, agency personnel, etc • Palmetto Hospital Trust initiated in 1999  DHEC 2/00 • Coordinator & Institutional support essential to success MISSION: To increase awareness of hepatitis C as major public health problem; increase education, treatment, and prevention activities among various target groups, including: HCWs, providers, patients, and the public. For primary care providers, establishes referral system for specialty care of patients with hepatitis C R. Ball, MD, MPH

  21. SC HEPATITIS C COALITION: TARGET GROUPS PUBLIC PATIENTS Problem for most people (if at-risk or not): where to get services? Health depts have no HCV resources; most docs don’t know... Needed services: - testing (EIA ~$10, RIBA ~$100) - counseling (ie, info prevention, Tx) - referral for services {~ HIV-AIDS} HEALTH CARE PROVIDERS HCWs SC Hepatitis C Coalition 803-898-9562

  22. SC HCC- 10 Accomplishments * 803-898-9562 • Organizational: education and awareness supported in-kind & in-house by SC DHEC - Mick Carnett, Coordinator CDP, CRPS, D.Div. • Informational & support services to providers, patients • Annual Statewide Hep C Summit (3rd on 11/14/02) • Statewide Physicians Referral List/ other >50 calls/ wk • Statewide 10 ETV program, 10’ HCC videos, 30” PSAs • Chapters in 3 sites: brochures/ literature; presentations R. Ball, MD, MPH

  23. SC Hepatitis C Coalition Activities 2002 • Operational: office, 501c3 status, grants (1x $40,000) • Meetings: monthly, + 2 chapters (upstate & coastal) • Presentations: > 30 (targeted/ general audiences > 3000) • 2 videos: >200 copies sent to providers & organizations • Communication w/ SCIDS, SCAGs re: medical services • www.ahec.net/hepatitis c SCHepC@bigfoot.com • Funding: Frontline Foundation, DAODAS, Schering, Roche, InterMune, NIOSH, misc. donations (~ $ 75K) R. Ball, MD, MPH

  24. “Those who carry on great public schemes must be proof against the most fatiguing delays, the most mortifying disappointments, the most shocking insults, and what is worst of all, the presumptuous judgments of the ignorant.” - Edmund Burke (1729 - 1797) Thank you. Questions ? DHEC Medical Consultation: 803-898-0861 R. Ball, MD, MPH

  25. HCV : Testing & Treatment Economics • EIA ($10) + RIBA/ PCR: 50,000 x (4) ~ $ 12 million+ • If wait until cirrhosis, eval., need liver transplants  • If 1 in 5, then need 10,000 livers in next decade(s) • Average cost of liver transplant ~ $ 300,000 • SC would need > $ 3 Billion for transplants ! • Curative treatments (~1/2 of patients) cost ~ $ 15,000 each for the (6-12 mos.) therapy  $ 750 million (max.), can prevent further transmission, new cases R. Ball, MD, MPH

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