Small Budget, Big Dreams: Missouri Hepatitis Prevention Scott Carson HCV Program Coordinator Bureau of HIV/STD/Hepatitis Section of Disease Control and Environmental Epidemiology Missouri Department of Health and Senior Services

Missouri 2003 Population: 5,704,484 St. Joseph St. Louis Kansas City Columbia The 5,704,484 population of Missouri is largely rural. The state is bracketed on the east and west by its two large metro areas—St. Louis and Kansas City—with the rest of the state referred to “out state.” Springfield Cape Girardeau

Major Population Centers: Kansas City: 442,768 Total Metro Area (MO): 982,410 St. Louis City: 332,223 St. Louis County: 1,009,235 1,981,879 KC is in Jackson County—essentially Jackson County IS KC St. Louis City is separate and distinct from St. Louis County. The city is viewed as a county and is geographically quite small. St. Charles County has a population of over 320,000 Franklin County has a population of over 98,000 Jefferson County has a population of over

This leaves 2,740,195 people living in “Out State Missouri.” You might think that people in rural Missouri look like this…

…when “out state” actually includes people in all age brackets and various races, living in areas with high concentrations of: Ethnic minorities Immigrants from Eastern Europe Methamphetamine and Injection Drug Use

Realities of Missouri public health: The State Laboratory is not funded to conduct HCV tests Only five LPHAs operate full time walk in STD/HIV testing clinics; others provide STD/HIV treatment/testing on scheduled days The disease reporting/tracking system is limited Local overtime and flex-time limitations inhibit off-site/off-hour testing events Reluctance on the part of the Department of Corrections and Correctional Medical Services to conduct HCV testing and allow HAV/HBV vaccination of incarcerated individuals MOHSAIC= Missouri Health Strategic Architecture and Information Cooperative is so inaccurate and undependable that many LPHAs have developed their own programs for tracking infections.

CDC Estimate: CDC estimates the US infection rate to be 1.8%. This could mean 102,681* Missourians with HCV. *Based on 2003 estimated population of 5,704,484 The 102,681 figure is reached by multiplying the state population by 1.8%. HOWEVER……

However, the number of known HCV infections in Missouri is… 23,455 HCV Reports by Year: Missouri 1999-2004 1999 2474 2000 4884 2001 8448 2002 1400 2003 3071 2004 3141 This is only 23% of the estimated number of HCV cases. Reporting of new cases fluctuates annually. Researchers in the St. Louis area estimate there are more than 36,000 people with HCV in metro St. Louis but known cases statewide are only 23,455 1.8 % of the General Population 3.9 million people infected in the U.S. 23,455 Missourians known to be infected. 8,000 – 10,000 Deaths Annually in U.S. from HCV related chronic liver disease. – this figure is from the CDC'S MMWR, October 16, 1998/vol. 47 / No. RR – 19 edition.

Partnerships are the Key The HIV C&T courses now include hepatitis modules Inter-agency collaboration facilitates HCV testing and referral Ongoing push by DHSS and partners to to make HCV testing available statewide DHSS seeking funding to upgrade State Laboratory capacity Columbia-Boone County HD HCV testing program (three year grant) MO Hepatitis C Alliance and Regional AIDS Interfaith Network (RAIN) HCV testing in NE Region (three year grant) Two month HCV testing pilot in Jefferson County by DHSS, Washington University, and Roche DHSS, DMH, ALF, and Roche pilot HCV testing project in methadone clinic yielded 60%-70% positivity rate DHSS HCV program partners with HIV C&T, HIV CPG, DIS DHSS HCV program collaborates with DMH on projects with high risk adults DHSS HCV encourages LPHAs to seek supplemental grant funding as a means to provide HCV testing DHSS HCV works closely with CBOs that operate HCV programs funded through grants DHSS HCV partners with non-profit and corporate partners to fund short term targeted testing projects

DHSS/JCHD/Wash U/Roche HCV Pilot Program : Duration: 12/05-2/06 HCV testing: At JCHD clinics At two area rehabilitation facilities County HD will provide referral Washington University will provide follow-up care Data from pilot will be included in proposal for the statewide testing project

Proposed Statewide HCV Testing Program: To be instituted in three phases: Year 1: Area of MO south of I-44 corridor Year 2: Area of MO between I-44 and I-70 Year 3: Area of MO north of I-70 corridor Testing to be offered at: Designated STD clinics Ryan White point of enrollment DMH Drug Treatment Centers ALF will coordinate follow-up and referral for HCV+ patients

Year Three Year Two Year One St. Joseph Kansas City St. Louis Columbia I-44 runs southwest from St. Louis through Springfield. I-70 runs west from St. Louis through Kansas City Springfield Cape Girardeau Year One

Missouri Hepatitis A/B Vaccination Initiative Funded with carry over budget funds Screening criteria: Persons with history of STDs Persons with multiple sex partners MSM IDU/Intra-nasal cocaine users HIV+ and HCV+ Occupation risks Incarcerated persons Any self-perceived risk Vaccination Use: Originally limited to STD clinics (5 LPHAs) In 2004 all interested LPHAs were invited to participate (over 80 enrolled) LPHAs use vaccine during outreach and off site activities LPHAs collaborate with CBOs to extend reach of initiative 30,398 doses shipped in 2004 In addition to HCV education, testing and referral DHSS HCV program operates the Missouri Hepatitis Vaccination Initiative, funded with carryover funds. The initiative provides free HAV and HBV immunizations to adults at-risk for hepatitis infection.

On the horizon: Legislation to be introduced proposing general revenue funds for DHSS HCV program HCV Summit: DHSS/LPHAs, CBOs/non-profits, universities, and pharmaceutical companies will map strategy for combating HCV in Missouri DHSS has just created the Bureau of HIV/STD/Hepatitis to emphasize broad based disease prevention interventions

QUESTIONS…?