Hepatitis C Surveillance: From nothing to something... Ami P. Gandhi, MPH Viral Hepatitis Prevention Coordinator Amanda Taylor Dinwiddie, MPH Hepatitis C Epidemiologist

Tennessee North Carolina Appalachia South Carolina Alabama Florida

Viral Hepatitis Surveillance in Georgia Acute HAV reportable Acute & chronic HBV reportable All past and present hepatitis C infections are reportable (-) HCV RNA not reportable State Electronic Notifiable Disease Surveillance System (SendSS) Web-based reporting system Lab reporting via manual entry by DPH staff, end users (PH staff, provider, hospitals), ELR

Where We Were and Where We Are Now... Hepatitis C Surveillance Where We Were and Where We Are Now...

Hepatitis C Disease Investigation HAV, HBV, HCV disease investigation training offered for all new district Epi/DIS staff Criteria for investigating hepatitis C cases: Patient is < 30 years old, or Patient (any age) has ALT > 200, or Documented seroconversion in past 12 months (any age) , or Reason for testing listed as “symptoms of acute hepatitis” (any age) , or Patient was reported to be symptomatic (any age) , or Possible health care related exposure (any age) , or As requested by state hepatitis epidemiologist

Where We Were VHPC was responsible for HCV surveillance, Epi, & prevention activities Know your state advocates! Include them on workgroups; inform them of your needs State advocacy efforts resulted in GA legislature allotting funds for HCV

State Hepatitis C Funding!!! GA Legislature allotted to DPH Epidemiology Program for Hepatitis C activities FY15 – $85,000 Hired 1 FT & 2 PT Data Entry Staff FY16 – Additional $150,000 specifically to hire additional Epi and for HCV testing

“You should use ELR,” they said. “It’ll be fun,” they said. October 2015 --- Began mapping HCV lab data November/December 2015 --- Data entry staff began linking labs, creating records from ELR February 2016 --- Began auto creating records and linking cases from ELR March 2016 --- Historical data from 2010-2015 dumped into SendSS ~1,900 new records created ~35,000 labs linked to existing records Still occasional glitches in ELR

HCV ELR and Manual Data Entry...so far As of November 29, 2016: 77,805 labs have been manually entered or updated since November 2014. Paper labs in storage date back to mid- 1990s ELR, as of November 29, 2016: 12,838 new patients have been created 732 new incidents created 61,623 labs have been linked to existing cases 43,456 labs defined as ‘not a case’ 196,454

Other Surveillance Activities Implemented 2016 CSTE HCV case definition Sweep of HCV records to confirm chronic infections ~9,000 cases confirmed at end of 2015 Quarterly cases status reports sent to district PH staff Student interns to clean and de-duplicate HCV data HBV ELR....in progress Using Epi Info 7 Visual Dashboard to conduct simple surveillance

EI7 Surveillance Dashboard Useful tool to conduct surveillance with minimal need for programming code Free software Links to data source (Excel) generated from SendSS query -2016 counts are lower because end of the year sweep/closeout has not yet been completed

EI7 Surveillance Dashboard See district workload for prioritized cases Monitor trends for confirmed acute HCV cases

EI7 Surveillance Dashboard Break down data by demographics, testing method, risk factors…etc.

Hepatitis C Surveillance: What We Know So Far

HCV Surveillance and Epi Disease investigations prioritized for patients age 30 years old and younger Significant increases statewide in young adults Largest increases in rural GA Predominantly white, both males and females Prescription Opioid and Heroin epidemic statewide, including metro Atlanta

Total Reported* and Confirmed^ Hepatitis C Infections, All Ages, Georgia, 2010-2015 Total Reported* and Confirmed^ Hepatitis C Infections, Ages 30 Years and Younger, Georgia, 2010-2015 We do review cases that are antibody positive only with no PCR done * Total reported includes confirmed acute, confirmed chronic, and cases with unknown infection status. ^ HCV infections are confirmed (acute or chronic) based on CSTE case definitions.

Hepatitis C Infections, Ages 30 Years and Younger, Georgia, 2011-2015 Hepatitis C Infections, Baby Boomers, Georgia, 2011-2015

Counts, next slide is rates

* Total reported includes confirmed acute, confirmed chronic, and cases with unknown infection status.

Perinatal^ Hepatitis C Infections and Provider Testing , Georgia 2011-2015 Testing recommendation for babies born to HCV+ women: anti-HCV testing after 18 months of age OR HCV RNA testing at or after infant’s first well-child visit at age 1-2 months. HCV RNA testing should be repeated at a subsequent visit. http://www.cdc.gov/hepatitis/hcv/hcvfaq.htm#section5   Total Reported* Tested correctly Antibody tested too early PCR tested too early PCR tested at/after 2 months, but not at/after 12 months 2011 6 8.5% 2 2.8% 3 4.2% 0.0% 1 1.4% 2012 17 23.9% 11 15.5% 2013 13 18.3% 8 11.3% 2014 20 28.2% 2015 15 21.1% 4 5.6% 7 9.9% Total 71 100.0% 14 19.7% 40 56.3% * Total reported includes confirmed acute, confirmed chronic, and cases with unknown infection status. ^Perinatal Hepatitis C includes cases ≤36 months of age. 38 perinatal cases have been reported in 2016 so far (additional 14 exposed at birth but tested PCR negative)

Total Reported Cases in 2015 Only 20-34% of all patients ages 30 years or younger answered CRF risk factor questions. Total Reported Cases in 2015 1250   Answered Question (%) Answered Yes (%) Contact of person w/ known HCV within past 6 mos 266 (21%) 59 (22%) Ever a contact of person w/ known HCV 280 (22%) 83 (30%) IVDU within last 6 mos 329 (26%) 184 (56%) Ever IVDU 393 (31%) 262 (67%) Tattoo within last 6 mos (any setting) 251 (20%) 57 (23%) Tattoo within last 6 mos (correctional) 424 (34%) 6 (1%) Incarcerated within last 6 mos 253 (20%) 91 (36%) Ever incarcerated 313 (25%) 164 (52%)

Situational Analysis Build upon what we already know about the HCV burden in GA and to identify potential partner sites Overlay HCV surveillance data with: Drug Overdose Data Available on DPH Online Analytical Statistical Information System (OASIS; oasis.state.ga.gov) Correctional sites Data match with: Vital Records HIV Epi Collaborate with Opioid Drug Overdose Epidemiologist (new CDC grant)

Using Surveillance for Program Planning State HCV testing funds being used to target testing in high prevalence areas Support for Rapid HCV and RNA testing at 5 Health Districts Barriers to getting South GA health districts to participate Support for Rapid HCV testing at 4 CBOs Collaborating with GA AETC and local providers to target HCV screening, linkage to care, & treatment education for primary care providers in high prevalence areas Edit: Fixed typo

Working with SendSS team to populate ALTs reported via ELR when associated with a HCV report Link negative ELR labs to existing HCV records Viral Hepatitis Epi Profile Work with South GA health departments to implement Rapid HCV testing

Ami Gandhi, MPH Viral Hepatitis Prevention Coordinator Ami. Gandhi@dph Ami Gandhi, MPH Viral Hepatitis Prevention Coordinator Ami.Gandhi@dph.ga.gov 404-463-6254 Amanda Dinwiddie, MPH Hepatitis C Epidemiologist Amanda.Dinwiddie@dph.ga.gov 404-463-8918