HCV epi overview

Brigg Reilley, NPAIHB,

Nat’l Program Epidemiologist,

brigg.reilley@ihs.gov

In 20 minutes, we will cover

• Transmission/trends

• Screening

• HCV estimates: national, IHS, OK

(federal), Cherokee

Disclosures

• My powerpoint formatting skills are truly apalling

Risk Factors for Transmission of Hepatitis C

Injection Drug Use Male-Male Sex

Needlestick Injury Heterosexual Sex Mother to Child

Blood Products

Hepatitis C Prevalence (NHANES estimate)

Armstrong GL, et al. Ann Intern Med. 2006;144:705-14.;

Chak E, et al. Liver Int. 2011;31:1090-1101

3.2 Million HCV Antibody positive

Possibly up to 7.1 Million HCV Antibody positive in US

Source: Denniston M, et al. Hepatology. 2012:55:1652-61.

NHANES Survey, United States, 2001-2008

Awareness of HCV Infection Status

Unaware of HIV infection

21%

Knowledge of HCV Infection

NHANES Survey: United States, 1988-1994 and 1999-2002

Prevalence of HCV Antibody, by Year of Birth

Source: Armstrong GL, et al. Ann Intern Med. 2006;144:705-14.

Year of Birth

HC

V P

revale

nce(%

)

1910

1988–1994

1999–2002

7.0

6.0

5.0

4.0

3.0

2.0

1.0

0

1920 1930 1940 1950 1960 1970 1980 1990

1945-1965

A 300% Increase in Hepatitis C –related

Hospitalization for AI/AN – 1995-2007

Byrd KK, et al Pub Hlth Rep 2011

HCV related mortality (CDC National Surveillance data, 2016)

• Rates nationally and among AI/AN

dropped slightly from 2015-2016

• But rates remain the highest of all race

ethnicities by far and double the national

rate (10.75/100,000 among AI/AN,

4.45/100,000 nationally)

OSDH recommends testing for the following

persons:

• Anyone born from 1945 through 1965.

• Anyone who has injected drugs, even just once or many years ago.

• Anyone with certain medical conditions, such as chronic liver

disease and HIV or AIDS.

• Anyone who has received donated blood or organs before 1992.

• Anyone with abnormal liver tests or liver disease.

• Anyone who has been exposed to the blood from a person who has

Hepatitis C.

• Anyone on hemodialysis.

• Anyone born to a mother with Hepatitis C

OK state data, 2015 acute HCV

• In 2015, a total of 92 cases reported and confirmed as

acute HCV in Oklahoma.

• 53.3% of these cases were among males, while 46.7%

were females.

• Age group 25-29 years of age had the most cases and

highest rates of all the diagnosed acute cases (21.7%).

• Whites made up 56.5% of the acute HCV cases were

White.

• 80.3% of acute HCV patients reported having two or

more sexual partners, while 62.5% reported using

needles for street drugs

Chronic Hepatitis C Infection Disproportionately

Affecting Oklahomans; OSDH Encourages Testing

For Release: April 26, 2017

• According to a newly released study, there are an estimated 94,200

Oklahomans living with Hepatitis C virus infection. Estimates were

developed by researchers at Emory University in conjunction with the

Centers for Disease Control and Prevention to better understand the

number of people in each state living with Hepatitis C.

• The Oklahoma State Department of Health (OSDH) is encouraging

residents to be tested for the virus as Oklahoma had the highest

estimated prevalence in the nation at 3.34 percent, while the national

prevalence was 1.67 percent. The report also indicates 523 Oklahomans

died due to Hepatitis C from 1999-2012, ranking our state among the

highest for Hepatitis C mortality.

Recommended Testing Sequence for Identifying

Current Hepatitis C Virus (HCV) Infection

Source: CDC. Testing for HCV infection: An update of guidance

for clinicians and laboratorians. MMWR. 2013;62(18).

* For persons who might have been exposed to HCV within the past 6 months, testing for HCV RNA or follow-up testing for HCV antibody is

recommended. For persons who are immunocompromised, testing for HCV RNA can be considered.

† To differentiate past, resolved HCV infection from biologic false positivity for HCV antibody, testing with another HCV antibody assay can be

considered. Repeat HCV RNA testing if the person tested is suspected to have had HCV exposure within the past 6 months or has clinical

evidence of HCV disease, or if there is concern regarding the handling or storage of the test specimen.

HCV

RNA Not detected Detected + -

No current HCV infection No HCV antibody detected Current HCV infection

Link to care Additional testing as appropriate†

STOP*

+ -

Slide courtesy AASLD Curriculum & Training

HCV Screening 2012-2017,

IHS federal sites, persons born 1945-1965

0

10

20

30

40

50

60

2012 2013 2014 2015 2016 2017

Universal HCV Screening,

Cherokee Nation From 8/16-12/17, the program screened

38,591 persons ages 20-69 for HCV

HCV Ab+ test reflexes to RNA confirmation

By Age Category (CNHS)

3.2%

3.9%

1.2%

23534

14387

670

0

5000

10000

15000

20000

25000

0.0%

0.5%

1.0%

1.5%

2.0%

2.5%

3.0%

3.5%

4.0%

4.5%

Younger Baby Boomers Older

Percent Positive

Number Tested

By Sex (CNHS)

4.5%

2.7%

15924

22654

0

5000

10000

15000

20000

25000

0.0%

0.5%

1.0%

1.5%

2.0%

2.5%

3.0%

3.5%

4.0%

4.5%

5.0%

Men Women

Percent Positive

Number Tested

HCV new diagnoses, IHS data

IHS HCV new dx by age group,

2005-2015, national

Age (Years) Number (rate per 100,000)

<15 150 (3.3)

15-24 2,085 (67)

25-39 8,302 (235)

40-54 14,234 (496)

55+ 5,032 (199)

IHS new HCV dx by birth

cohort, 2005-2015, national

Birth Cohort Number (rate per 100,000)

Born Before 1945 1,118 (101)

Born 1945-1965

(Baby Boomers)

15,900 (478)

Born After 1965 12,785 (105)

IHS new HCV dx by sex,

2005-2015, national

No. (Rate/100,000)

Sex

Male 15,362 (193)

Female 14,441 (166)

IHS new HCV dx by region 2005-2015,

(national data) Region

Number (rate per

100,000)

Rate Ratio, 95%

Confidence Interval

P value

Alaska 2,743 (179) 0.81 (0.77-0.84) <0.0001

East 1,051 (197) 0.89 (0.84-0.95) 0.0005

Northern Plains East 1,875 (166) 0.75 (0.71-0.79) <0.0001

Northern Plains West 4,801 (224) 1.01 (0.98-1.05) 0.4462

Southern Plains 7,986 (221) Reference Reference

Southwest 5,538 (98) 0.44 (0.43-0.46) <0.0001

West 5,809 (286) 1.29 (1.25-1.34) <0.0001

Total 29,803 (179)

Cascade of Care, OK sites

Site 1 Site 2 Site 3 Site 4 Psite 5 Site 6 Site 7 Site 8 Comments

HCV Ab+ 800 323 79 181 233 136 16 1768

Ab+, RNA

neg

172 101 5 17 110 46 1 452 No further clinical

follow up needed

Ab+, RNA

unk

228 57 30 50 0 7 6 378 Need RNA testing

RNA + 400 160 44 114 144 60 7 929 Need to be cured

RNA+ and

Metavir 3-4

76 44 4 2 11 0 137 Late stage disease

need treatment ASAP

RNA+ and

Metavir 0-2

230 111 15 65 13 5 439

RNA+ and

Metavir unk

94 5 25 47 144 36 2 353 Need to have metavir

calculated

Currently in

tx

8 5 4 7 1 2 2 0

Treatment

complete,

SVR

106 48 8 48 7 15 15 2 Cured. Excellent

numbers

Treatment

complete,

SVR pending

18 23 3 11 13 6 6 0

Summary

• OKC Area is doing well overall compared

to other Areas, but each site needs

support to address gaps in the Cascade of

Care, namely

• Linking HCV patients to care for RNA

testing and Metavir scoring

• Increasing number of HCV patients in

treatment to cure existing patients in a

timely manner

Barriers ranked by SUs

• SUs cited the main barriers to increasing

HCV services as 1) needing more time to

work on HCV clinical services, 2)

contacting historical HCV patients to return

to care for confirmation or treatment, and

navigating the drug acquisition process.