Perinatal Hepatitis C in Kentucky Kathy J. Sanders, RN MSN Kentucky Department for Public Health Adult Viral Hepatitis Prevention Coordinator December 2016 NASTAD Conference

Disclosures Kathy Johnson Sanders, RN MSN and the Kentucky Department for Public Health have no relevant financial relationships with commercial interests to disclose.

Objectives Background Methods Results Discussion/Conclusions

Rates of Acute Hepatitis C Virus (HCV) Infections 2007-2013 http://www Kentucky West Virginia Indiana Kentucky, West Virginia, Indiana and TN in top four COMPILED DATA FROM SOURCE: http://www.cdc.gov/hepatitis/statistics/ States with consistent reporting (RATES ONLY) 2007 2008 2009 2010 2011 2012 2013 Alabama 0.2 0.3 0.2 0.1 0.5 0.5 0.6 Arkansas 0.0 0.0 0.1 0.0 0.0 0.2 1.0 California 0.2 0.1 0.1 0.1 0.1 0.2 0.2 Colorado 0.4 0.3 0.6 0.4 0.5 0.8 0.4 Florida 0.1 0.2 0.3 0.3 0.3 0.6 0.7 Georgia 0.2 0.2 0.3 0.3 0.5 0.8 0.5 Idaho 0.3 0.2 0.5 0.7 0.8 0.7 0.9 Illinois 0.1 0.1 0.0 0.0 0.0 0.2 0.3 Indiana 0.2 0.2 0.3 0.4 1.3 1.7 2.7 Kentucky 0.7 1.6 1.5 2.5 3.2 4.1 5.1 Louisiana 0.1 0.2 0.2 0.1 0.2 0.2 0.4 Maine 0.1 0.2 0.2 0.2 0.9 0.6 0.6 Maryland 0.3 0.4 0.4 0.4 0.6 0.7 0.9 Michigan 0.9 1.3 0.4 0.5 0.3 0.8 0.7 Minnesota 0.5 0.4 0.3 0.3 0.3 0.6 0.9 Missouri 0.1 0.0 0.0 0.1 0.1 0.1 0.1 Nevada 0.4 0.8 0.2 0.3 0.4 0.4 0.3 New Jersey 1.1 0.7 0.1 0.3 0.6 0.8 1.2 New Mexico 0.3 0.3 0.3 0.7 0.7 1.0 0.6 New York 0.2 0.2 0.3 0.3 0.3 0.5 0.7 North Carolina 0.2 0.5 0.3 0.4 0.6 0.6 0.8 Ohio 0.2 0.3 0.2 0.1 0.1 0.1 1.0 Oklahoma 1.4 0.5 0.7 1.1 1.4 2.1 1.0 Oregon 0.4 0.6 0.5 0.5 0.5 0.9 0.4 Pennsylvania 0.3 0.2 0.3 0.2 0.3 0.5 0.6 Tennessee 0.6 0.4 0.5 0.7 1.3 2.0 1.5 Texas 0.3 0.2 0.1 0.1 0.1 0.2 0.1 Utah 0.2 0.4 0.2 0.4 0.4 0.6 0.4 Vermont 1.5 0.2 0.2 0.3 1.0 1.0 0.5 Virginia 0.1 0.1 0.1 0.2 0.3 0.9 0.5 Washington 0.3 0.4 0.3 0.4 0.6 0.8 0.9 West Virginia 1.0 1.2 1.7 1.1 2.5 3.0 3.1 Wisconsin 0.0 0.1 0.1 0.2 0.3 0.5 0.7   Tennessee

Incidence of acute hepatitis C among persons aged 20-29 years, by urbanicity and year– Kentucky, Tennessee, Virginia, and West Virginia, 2006-2012 http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6417a2.htm?s_cid=mm6417a2_w Non-urban Urban SOURCE: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6417a2.htm?s_cid=mm6417a2_w

Background In 2012, Kentucky Adult Viral Hepatitis Prevention Program partnered with selected local health departments (LHDs) for HCV laboratory testing pilot project for individuals with identified risk factors Results: Identified a large number of confirmed HCV-positive tests in the 20-29 age group Raised concerns about the potential for mother-to-child transmission of HCV Over 8300 tested. 12% positive rate, 79% of positives reported history of IDU, 94.5% white non Hispanic. Interestingly, MSM represented 4.6% of those tested, yet only 2.2% of the MSM were HCV positive.

Methods In late December 2013, DPH requested voluntary reporting from healthcare providers across Kentucky for: All HCV-positive pregnant women All infants born to HCV-positive women All HCV-positive children aged 5 years or less Reporting was mandated by law in Feb 2015

CDC- Top 220 US Counties http://www. kyrha In early 2015, Scott County Indiana…..October 2015, the Dr. John Brooks CDC released the “Top 220 U.S. Counties with Increased Vulnerability to Rapid Dissemination of HIV/HCV Infections among IDU

CDC- 55 High Risk Counties in Kentucky Fifty five counties of the 120 counties in Kentucky were identified as being high risk.

Mothers or Pregnant Women Results: Dec 2013 to Nov 2016  Age Groups Cases Mothers or Pregnant Women 1651 ≤20 72 21-24 391 25-29 610 30-34 341 35-39 139 40+ 26 Unknown Children 731 ≤12 Months 325 >12 Months 360 unknown Pregnant Women (n=1651) Children (n=731)

Results Mothers or Pregnant Women (n=1651) Age<18 months (n=579)   HCV RNA+ HCV RNA- No HCV RNA Total HCV Ab+ 222 58 1094 1374 HCV Ab- 1 4 5 No HCV Ab 64 207 272 287 59 1305 1651  Age<18 months (n=579) 16 10 33 29 20 466 515 45 34 500 579  Age ≥ 18 months (n=106) 13 22 39 9 7 3 48 79 106

Risk Factors of Mothers or Pregnant Women Results Risk Factors of Mothers or Pregnant Women Yes No/Unknown % with risk factor Intravenous Drug Use 608 1043 36.8% Multiple Sex Partners 162 1489 9.8% STD 59 1592 3.6% HIV 5 1636 0.3% Exposure to Known HBV/HCV Positive Contact 57 1594 3.5% Foreign-Born 1 1650 0.1% Incarceration ** 26 688 3.7% ** new data system Gentrack, now monitoring reported reports of incarceration

MMWR- Increased Hepatitis C Virus (HCV) Detection in Women of Childbearing Age and Potential for Vertical Transmission- United States and Kentucky, 2011-2014

Discussion Results in MMWR indicated that from 2011-2014, HCV detection among women of child bearing age in Kentucky increased 213% from 275 to 862 per 100,000. 1 in 63 births in Kentucky About 80% have current disease when HCV RNA is reported Multiple risk factors are associated with pregnant women and mothers with HCV Vertical transmission of HCV is occurring in Kentucky Not limited to urban centers MMWR Report:

Creating Outreach/ Awareness: Healthcare systems throughout Kentucky KY Maternal Child Health- Neonatal Abstinence Syndrome KY Cabinet for Health and Family Services- Division of Protection and Permanency Local Health Department (LHD)- Core Clinical Service Guide (CCSG) implementation of HCV testing and referral protocols WIC Program Well Child Visits-Documentation and reminders in the Electronic Medical Record Flow Charts in the CCSG created for LHD screening, testing, and referral * University of Kentucky not testing pregnant women coming in to labor, several reasons: not recommended by ACOG and these women are coming in to deliver and leaving AMA within 24 hours- reports showing moms delivering in woods, gas stations, hotels . We believe our data speaks for itself and warrants…Currently working with Commissioners office to add verbiage in regulations for all pregnant in KY women to be HCV tested. * NAS became reportable in July 2014, working on cross analyzing data.- Working with commissioners office to add to regulations to add HCV antibody testing for newborn NAS. Louisville infant abandoned, mother injecting in ER- IV. Was not able to get babies history, so HCV tested. * Training to foster families. Mandatory ATV training being produced.

LHD Guidance NAS became reportable in July 2014, cross analyzing data.

LHD Guidance NAS became reportable in July 2014, cross analyzing data. Training to foster families. Mandatory ATV training being produced.

Conclusion Identified pregnant women are only the tip of iceberg Lack of tailored education and awareness campaigns about HCV transmission, particularly in rural areas of the state, need to be implemented. Kentucky Public Health officials support increased surveillance of HCV- recently approved to receive ASTHO grant funds to develop a Kentucky Epidemiologic Profile Legislation was passed in February to make perinatal HCV a reportable disease in KY, effective Feb 26, 2015 Recent approval (November 2016) in Legislature of amended form to report HCV in pregnant women, infants born to HCV-positive mothers, and HCV in children aged five years or less Faxed reports are now being entered into a tracking system for analysis Development of a Kentucky Hepatitis Position Statement We need boots on the ground! In the past, EPI info was used for data entry. Currently epidemiologists donated from other programs have assisted in entering and analyzing the data. With the GENTRACK system, LHD’s and birthing centers could enter their data into this system and track their regions/ centers perinatal data. Emergency funds!!!

Limitations Voluntary testing of high risk pregnant women- Not ACOG recommended Post Partum Follow up of women identified as HCV positive, RNA confirmation and linkage to care Incarcerated pregnant women Need HCV test panel for pregnant women similar to HBV test panel Follow up testing and monitoring of infants born to mothers with HCV infection- foster care, placement with family members Data entry and analysis

Acknowledgements Co-authors Robert Brawley, MD, MPH, FSHEA Hollie Sands, MPH Tori Amburgey, MPH Kentucky Department for Public Health, Division of Epidemiology and Health Planning Kentucky Local Health Departments and Private Providers/ Birthing Centers who voluntarily reported in 2013 and 2014 and reported after law became effective in 2015

Kathy J. Sanders KathyJ.Sanders@ky.gov 502-564-3261 ext. 4236 Thank You Kathy J. Sanders KathyJ.Sanders@ky.gov 502-564-3261 ext. 4236