DISCLOSURES This activity is jointly provided by Northwest Portland Area Indian Health Board and Cardea Cardea Services is approved as a provider of continuing nursing education by Montana Nurses Association, an accredited approver with distinction by the American Nurses Credentialing Center’s Commission on Accreditation. This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Institute for Medical Quality/California Medical Association (IMQ/CMA) through the joint providership of Cardea and Northwest Portland Area Indian Health Board. Cardea is accredited by the IMQ/CMA to provide continuing medical education for physicians. Cardea designates this in-person training for a maximum of 7 AMA PRA Category 1 Credit(s)TM. Physicians should claim credit commensurate with the extent of their participation in the activity.  

DISCLOSURES COMPLETING THIS ACTIVITY Upon successful completion of this activity 7 contact hours will be awarded Successful completion of this continuing education activity includes the following: Attending the entire CE activity; Completing the online evaluation; Submitting an online CE request. Your certificate will be sent via email If you have any questions about this CE activity, contact Michelle Daugherty at mdaugherty@cardeaservices.org or (206) 447-9538

CONFLICT OF INTEREST None of the planners or presenters of this CE activity have any relevant financial relationships with any commercial entities pertaining to this activity.

Acknowledgement This event is funded in part by:     This event is funded in part by: The Indian Health Service HIV Program and The Secretary’s Minority AIDS Initiative Fund

Objectives  By the end of this learning event participants will be able to: Define elimination as it relates to infectious disease Identify interventions required to achieve HCV elimination Describe Lummi HCV elimination program  

Starting a Hepatitis C Elimination Program at Lummi Justin Iwasaki MD MPH Executive Medical Director Lummi Tribal Health Center

World Health Organization Elimination Reduction to zero of the incidence of disease or infection in a defined geographical area. World Health Organization HCV ELIMINATION http://www.who.int/bulletin/volumes/84/2/editorial10206html/en/

HCV is a Public Health Problem Requiring a Public Health Response Treatment as Prevention HCV ELIMINATION

Incidence of Acute Hepatitis C by Race/Ethnicity (USA) Source: National Notifiable Diseases Surveillance System (NNDSS)

80% of New HCV Infections Occur in People Who Inject Drugs (PWID) Source: National Notifiable Diseases Surveillance System (NNDSS)

Super Infectors +Usual Infectors+Non-Infectors HCV ELIMINATION

HCV Program Design Considerations PWID May Not Fit the Usual Healthcare Delivery Model We Created Scheduled Office Visits Follow Up with Testing and Imaging and Future Appointments Convenient Contact with Telephone or Mail Reliable Transportation Ability to Safely Store Medication Predictable Changes to Home Life: Hospitalization, Incarceration, Drug/Alcohol Rehab Family and Friend Support HCV ELIMINATION

We Had to Create A New Model of Healthcare Delivery HCV ELIMINATION

Cascade of Care Example from the University of BC This is just an example from the Univeristy of British Columbia, but I like the simplicity. It is easy to model a database after, and to identify categories and trends. The goal of course being to reverse the chart, move the diagnosed patient population to the cured population. We have been attempting this by increasing Screening, community education, and we are working on developing more specific plans tailored to patients with less stable lifestyles. Again remembering what works for one patient could be impossible to for another patient to adhere to Example from the University of BC

Two Components of the Program Getting the Patient Ready for Treatment Treatment and Monitoring HCV ELIMINATION

Getting the Patient Ready for Treatment HCV Project Coordinator (RN) and Assistant Initially, required multiple visits, could not get outside imaging, significant amount of human resources. Partnered with NWPAIHB to Establish a Single Visit Ready to Treat Program HCV ELIMINATION

Single Visit Ready to Treat Program Day 0 Rapid HCV Ab Test Positive Negative HCV RNA with Reflex to Genotype (standing orders) BMP LFT INR CBC *Fibroscan Re-Screen Based on Exposure History Day 1 No Chronic HCV Chronic HCV Retest HCV RNA q6month Present to Project ECHO Submit Prior Authorization 4-6 Weeks Start Treatment

Fibroscan: calculates liver stiffness based on sound wave. Non-invasive. 10-15 Minutes. RN, Rad Tech, MD HCV ELIMINATION

Treatment and Monitoring Medication Compliance Daily, Weekly, Bi-Monthly Partner with Opioid Treatment Program Home Visits and Outreach HCV ELIMINATION

Lummi HCV Cascade of Care 74% Number of Patients I need the total number of unique patients tested in the time frame that the 366 patients were positive to estimate the seropositivity 73% 79%

Screened 1861 of 5775 Adult Patients for HCV Initiating Treatment ~5 Patients Per Month Eliminate HCV 2021* HCV ELIMINATION

All Patients Care About Treatment Untreated bipolar, homeless/living on sail boat,frequent drug use. YWCA, Shelter, ER. Arrested Patient: “Not Without My Harvoni” HCV ELIMINATION

Jessica Leston and David Stephens NWPAIHB Thank You Jessica Leston and David Stephens NWPAIHB Dr. Jorge Mera Jessica Rienstra HCV Project Coordinator Kim Schiller HCV Project Assistant HCV ELIMINATION