Embed Size (px)
Citation preview
Public Health Response to HCV in
Oregon: Need for Screening and
Treatment
November 29, 2018
Ann Thomas, MD, MPH
Acute and Communicable Disease
Prevention
Public Health Division
2
Outline
I. Epidemiology of HCV in OR
– acute HCV, chronic HCV in persons <30
– chronic HCV, liver cancer and mortality
II. Public Health Response
– Harm reduction approaches
– Treatment as prevention
– Lessons learned from HIV prevention
Public Health Division
3
Estimates of number of
Oregonians with HCV
• 75,090
– Number reported to Oregon’s HCV
registry by September 2018
• 100,000 +
– Actual number assuming that at least
50% of Oregonians with HCV are
unaware of their diagnosis
Public Health Division
4
Acute HCV cases by sex and
age, Oregon, 2012-2016 (n=103)
0
2
4
6
8
10
12
14
16
18
20
0-19 20s 30s 40s 50s 60s 70 and up
Num
ber
of C
ases
Age Group
Male
Female
IDU, 62.5%
Potential Healthcare Exposure*,
12.5%
Multiple Sex Partners, 6.3%
Other Risk**, 18.8%
*Transfusion, infusions, dialysis and surgery
**street drugs, needle stick, tattoo, piercing, contact of a case,
and other blood exposure
Reported Risk Factors
for Acute Hepatitis C, Oregon, 2016
Public Health Division
6
Rate of women who are HCV+, as reported on
birth certificate (per 1,000 live births), Oregon
2012-2016
0.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
4.0
4.5
2012 2013 2014 2015 2016
N=137 cases
N=184 cases
• 34% increase between 2012 and 2016
Number of Chronic HCV cases,
Oregon, 2012-2016
2012 2013 2014 2015 2016
30+ 4249 3696 4960 5290 5156
< 30 515 561 676 712 816
0
1000
2000
3000
4000
5000
6000
7000
• 58% increase in cases < 30 years
Public Health Division
8
Cases of liver cancer with HBV and HCV
Oregon, 1996-2012
• In 2012, 47% of persons with liver cancer had chronic HCV
0
50
100
150
200
250
300
350
1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
Nu
mb
er
of
Cases o
f L
iver
Can
cer HCV (n=763)
HBV (n=196)
No Hep
Source: Oregon Center for Health Statistics
0.00
2.00
4.00
6.00
8.00
10.00
12.00
Ag
e-a
dju
ste
d r
ate
pe
r 1
00
,00
0
po
pl
Hepatitis C-related deaths in
Oregon and US, 2000–2015
0.00
2.00
4.00
6.00
8.00
10.00
12.00
Ag
e-a
dju
ste
d r
ate
pe
r 1
00
,00
0 p
op
l
Oregon
USA
Oregon has the highest HCV-related mortality rate in the US
Public Health Division
10
Epidemiology Summary
• High prevalence (3rd highest in country according
to CDC) and mortality of HCV in Oregon
• Most common in baby boomers, who bear
biggest burden of sequelae of HCV-related liver
cancer, death
• Increasing cases in younger Oregonians, more
likely to be associated with injection drug use
Public Health Perspective:Risk of HCV Transmission and HCV Progression of Persons
Who Inject Drugs (PWIDS)
3515 25 5545 65Years of age
Population Level
Risk of HCV transmission
Individual Level
Risk of HCV and liver-related
morbidity and mortalityHighest prevalence
of PWIDs
• Highest risk of HCV
transmission due to
tendency of people new to
injection drug use to share
injection equipment
• Highest prevalence
of PWIDs 2
• Moderate risk of
advanced liver
disease
• Moderate risk of
HCV transmission
• Highest prevalence
and risk of advanced
liver disease
• Lower risk of HCV
transmission
Classic Public Health
Approach• Primary Prevention
(prevent new
infections)
– Harm reduction,
Medication Assisted
Treatment, and
Syringe Exchange
Programs
– Treat with DAAs to
reduce transmission
• Secondary Prevention
(screen and treat
before disease
progresses)
– Screening of persons
at risk and all persons
born 1945-1965
– Monitor for liver cancer
– Treat with DAAs to
reduce morbidity and
mortality
Public Health Division
13
HCV treatment as prevention
• Recent studies modeling the impact of DAAs
on HCV transmission:
1. Can eliminate HCV in 10 years by treating 12% of
PWID population
2. Treat 25% OR treat 15% plus MAT and SEP for
90% reduction in 15 years
High impact on disease transmission with
modest numbers needed to treat
1. Zelenev Lancet Infect Dis 2018;18:215; 2. Fraser Addiction 2018;113:173
Public Health Division
14
Advantages of dropping
fibrosis score requirements
• Lack of available treatment has been barrier
to screening
• If fibrosis score not required, work-up is
simplified
– Can determine if cirrhosis present from serum
fibrosis markers
– No Fibroscan or ultrasound elastography needed
– Easier for primary care clinicians to treat HCV
Age-adjusted Death Rates for HCV and
HIV, Oregon, 1993–2013
How antiretroviral treatment
changed the curve for HIV
0.00
2.00
4.00
6.00
8.00
10.00
12.00A
ge-a
dju
ste
d r
ate
pe
r 1
00
,00
0
HCV
HIV
HIVHCV
Advent of
HAART
Public Health Division
16
Public Health Lessons for HCV
from HIV
• Case management should be acuity-based
• Training and supporting primary care clinicians
(ECHO, MAT training)
Public Health Division
17
Questions
Public Health Division
18
Extra Slides
Public Health Division
19
Resources
Program Development and ManagementClinic• Clinic Consultation
• Quality Improvement
• Practice Transformation
• Guidelines and Toolkits (e.g. HRSA-AETC)
Education and Mentoring (HCV and HIV)Provider• Clinician Consultation Center (UCSF CCC “Warm line”)
• Tele-education and mentoring
• 1 to 1 Clinician detailing
• Online self-paced study
Public Health Division
20
Oregon Resources• Oregon AIDS Education Training Center (OR -AETC)
– Clinic consultation, quality improvement, public health detailing and practice
transformation support (HIV/HCV)
– Oregon HIV ECHO
– Contact [email protected]
• Oregon ECHO Network (OEN)– Builds capacity of primary care clinicians and teams
– Technology, Disease Management Model and Case Based Learning
– Contact [email protected]
• Oregon Hepatitis C Screening Initiative (OR-HCV)– Clinic consultation and quality improvement support
– Small stiped: implement HCV EHR report and determine site’s baseline
HCV screening rate, share screening rates quarterly and implement at least
one provider focused intervention.
– Contact [email protected]
