HCV epi overview Brigg Reilley, NPAIHB, Nat’l Program Epidemiologist, brigg.reilley@ihs.gov

In 20 minutes, we will cover Transmission/trends Screening HCV estimates: national, IHS, OK (federal), Cherokee

Disclosures My powerpoint formatting skills are truly apalling

Risk Factors for Transmission of Hepatitis C Injection Drug Use Blood Products Male-Male Sex Mother to Child Heterosexual Sex 68% IDU 18% sexual 9% unknown 4% occupational 1% other Needlestick Injury

Hepatitis C Prevalence (NHANES estimate) 3.2 Million HCV Antibody positive Possibly up to 7.1 Million HCV Antibody positive in US Armstrong GL, et al. Ann Intern Med. 2006;144:705-14.; Chak E, et al. Liver Int. 2011;31:1090-1101

Knowledge of HCV Infection Unaware of HIV infection 21% NHANES Survey, United States, 2001-2008 Awareness of HCV Infection Status Knowledge of HCV Infection Unaware of HIV infection 21% Other surveys have even more disappointing results: Smith B et al MMWR 2012; 61 (RR-4): 1-32 45-85% unaware of their status Among high-risk populations, testing rates are 17%-87% ~70% of IDU’s witih HCV are unaware of their status Reasons Why: No insurance, limited access to care, accuracy of pt recall of risk, patients uncomfortable disclosing risk factors, time constraints, provider reluctance Source: Denniston M, et al. Hepatology. 2012:55:1652-61. 1

NHANES Survey: United States, 1988-1994 and 1999-2002 Prevalence of HCV Antibody, by Year of Birth HCV Prevalence(%) 1910 1988–1994 1999–2002 7.0 6.0 5.0 4.0 3.0 2.0 1.0 1920 1930 1940 1950 1960 1970 1980 1990 1945-1965 Priority populations: baby boomers (born 1945-1965) currently aged 45-65 Baby Boomers have a HCV infection rate of 1 in 33 (3%) Still about 20,000 new infections per year, mainly in IDU population Source: Armstrong GL, et al. Ann Intern Med. 2006;144:705-14.

A 300% Increase in Hepatitis C –related Hospitalization for AI/AN – 1995-2007 Byrd KK, et al Pub Hlth Rep 2011

HCV related mortality (CDC National Surveillance data, 2016) Rates nationally and among AI/AN dropped slightly from 2015-2016 But rates remain the highest of all race ethnicities by far and double the national rate (10.75/100,000 among AI/AN, 4.45/100,000 nationally)

OSDH recommends testing for the following persons: Anyone born from 1945 through 1965. Anyone who has injected drugs, even just once or many years ago. Anyone with certain medical conditions, such as chronic liver disease and HIV or AIDS. Anyone who has received donated blood or organs before 1992. Anyone with abnormal liver tests or liver disease. Anyone who has been exposed to the blood from a person who has Hepatitis C. Anyone on hemodialysis. Anyone born to a mother with Hepatitis C

OK state data, 2015 acute HCV In 2015, a total of 92 cases reported and confirmed as acute HCV in Oklahoma. 53.3% of these cases were among males, while 46.7% were females. Age group 25-29 years of age had the most cases and highest rates of all the diagnosed acute cases (21.7%). Whites made up 56.5% of the acute HCV cases were White. 80.3% of acute HCV patients reported having two or more sexual partners, while 62.5% reported using needles for street drugs

Chronic Hepatitis C Infection Disproportionately Affecting Oklahomans; OSDH Encourages Testing For Release: April 26, 2017 According to a newly released study, there are an estimated 94,200 Oklahomans living with Hepatitis C virus infection. Estimates were developed by researchers at Emory University in conjunction with the Centers for Disease Control and Prevention to better understand the number of people in each state living with Hepatitis C. The Oklahoma State Department of Health (OSDH) is encouraging residents to be tested for the virus as Oklahoma had the highest estimated prevalence in the nation at 3.34 percent, while the national prevalence was 1.67 percent. The report also indicates 523 Oklahomans died due to Hepatitis C from 1999-2012, ranking our state among the highest for Hepatitis C mortality.

Recommended Testing Sequence for Identifying Current Hepatitis C Virus (HCV) Infection - HCV antibody + Nonreactive Reactive - HCV RNA Not detected + Detected No HCV antibody detected No current HCV infection Current HCV infection STOP* Additional testing as appropriate† Link to care * For persons who might have been exposed to HCV within the past 6 months, testing for HCV RNA or follow-up testing for HCV antibody is recommended. For persons who are immunocompromised, testing for HCV RNA can be considered. † To differentiate past, resolved HCV infection from biologic false positivity for HCV antibody, testing with another HCV antibody assay can be considered. Repeat HCV RNA testing if the person tested is suspected to have had HCV exposure within the past 6 months or has clinical evidence of HCV disease, or if there is concern regarding the handling or storage of the test specimen. Source: CDC. Testing for HCV infection: An update of guidance for clinicians and laboratorians. MMWR. 2013;62(18). Slide courtesy AASLD Curriculum & Training

HCV Screening 2012-2017, IHS federal sites, persons born 1945-1965 OK SUs 62% Tribal sites lower nationally

Universal HCV Screening, Cherokee Nation From 8/16-12/17, the program screened 38,591 persons ages 20-69 for HCV HCV Ab+ test reflexes to RNA confirmation

By Age Category (CNHS)

By Sex (CNHS)

HCV new diagnoses, IHS data

IHS HCV new dx by age group, 2005-2015, national Age (Years) Number (rate per 100,000)  <15 150 (3.3) 15-24 2,085 (67) 25-39 8,302 (235) 40-54 14,234 (496) 55+ 5,032 (199)

IHS new HCV dx by birth cohort, 2005-2015, national  Number (rate per 100,000) Born Before 1945 1,118 (101) Born 1945-1965 (Baby Boomers) 15,900 (478) Born After 1965 12,785 (105)

IHS new HCV dx by sex, 2005-2015, national   No. (Rate/100,000) Sex Male 15,362 (193) Female 14,441 (166)

IHS new HCV dx by region 2005-2015, (national data) Number (rate per 100,000)  Rate Ratio, 95% Confidence Interval  P value  Alaska 2,743 (179) 0.81 (0.77-0.84) <0.0001 East 1,051 (197) 0.89 (0.84-0.95) 0.0005 Northern Plains East 1,875 (166) 0.75 (0.71-0.79) Northern Plains West 4,801 (224) 1.01 (0.98-1.05) 0.4462 Southern Plains 7,986 (221) Reference Southwest 5,538 (98) 0.44 (0.43-0.46) West 5,809 (286) 1.29 (1.25-1.34) Total 29,803 (179)  

Cascade of Care, OK sites

  Site 1 Site 2 Site 3 Site 4 Psite 5 Site 6 Site 7 Site 8 Comments HCV Ab+ 800 323 79 181 233 136 16 1768 Ab+, RNA neg 172 101 5 17 110 46 1 452 No further clinical follow up needed Ab+, RNA unk 228 57 30 50 7 6 378 Need RNA testing RNA + 400 160 44 114 144 60 929 Need to be cured RNA+ and Metavir 3-4 76 4 2 11 137 Late stage disease need treatment ASAP RNA+ and Metavir 0-2 230 111 15 65 13 439 RNA+ and Metavir unk 94 25 47 36 353 Need to have metavir calculated Currently in tx 8 Treatment complete, SVR 106 48 Cured. Excellent numbers Treatment complete, SVR pending 18 23 3

Summary OKC Area is doing well overall compared to other Areas, but each site needs support to address gaps in the Cascade of Care, namely Linking HCV patients to care for RNA testing and Metavir scoring Increasing number of HCV patients in treatment to cure existing patients in a timely manner

Barriers ranked by SUs SUs cited the main barriers to increasing HCV services as 1) needing more time to work on HCV clinical services, 2) contacting historical HCV patients to return to care for confirmation or treatment, and navigating the drug acquisition process.