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

2. Tennessee
North Carolina
Appalachia
South Carolina
Alabama
Florida

3. 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

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

5. 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

6. 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

7. 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

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

9. 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

10. 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

11. 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

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

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

14. Hepatitis C Surveillance: What We Know So Far

15. 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

16. 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,
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.

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

18. Counts, next slide is rates

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

20. 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.
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)

21. 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%)

22. 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)

23. 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

24. 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

25. Ami Gandhi, MPH Viral Hepatitis Prevention Coordinator Ami. Gandhi@dph
Ami Gandhi, MPH Viral Hepatitis Prevention Coordinator
Amanda Dinwiddie, MPH Hepatitis C Epidemiologist