1. Cherokee Nation HCV Program: From Evaluation to Cure to Elimination
Jorge Mera, MD, FACP
Whitney Essex, MSN, FNP-BC

2. Objectives Define elimination as it relates to infectious diseases
Identify interventions required to achieve HCV elimination
Describe the CNHS HCV Elimination program

3. Considerations: Elimination
National Academies of Sciences, Engineering and Medicine (formerly IOM)
Released report on April 11, 2016
Committee determined that:
Both hepatitis B and C could be rare diseases in the US
Considerable will and resources would be required to do this
Released report in April 2017 addresses what steps must be taken
Available at: nas.edu/hepatitiselimination
Decrease the incidence of HCV by 90 % and mortality by 65 %
by the year 2030 3

4. Unsafe Medical Practices Harm Reduction Strategies
Linkage to Care
Quality of Care
Screening
HCV
Unsafe Medical Practices
IVDU
Harm Reduction Strategies
Poverty
Domestic Violence
Mental Illness
Historical Trauma
Cultural
Disconnection
others
Prevention

5. Discovery of HCV and Impact on HCV Incidence in US
Incident cases per 100,000 persons
Discovery of HCV
1989
HCV Incidence Was Highest Before the Discovery of HCV. Prevention Strategies have had a huge impact on incidence in United States
And rates dropped but you note a slight uptick nationally starting in 2010
(John,
I couldn’t get 2012 data to appear on the x-axis.
Please verify that label for
Please take a moment to emphasize the PH triumphs these points represent.
A larger risk of HCV transmission before prevention interventions
1987 Universal precautions
1991 OSHA blood borne pathogen standard
1992 Screening blood transfusions for HCV antibody
2001 Needle stick safety and prevention act )
Year
22,000 cases of incident HCV infection reported in 2012
Alter MJ JAMA 1990; Jagger J, J infect Dis Pub Health 2008; CDC.gov/hepatitis;

6. Definitions Control: Elimination: Eradication
The reduction of disease incidence, prevalence, morbidity or mortality to a locally acceptable level as a result of deliberate efforts; continued intervention measures are required to maintain reduction. Example: diarrheal diseases
Elimination:
Reduction to zero of the incidence of infection caused by a specific agent in a defined geographical area as a result of deliberate efforts; continued measures to prevent re- establishment of transmission are required. Example: measles, poliomyelitis.
Eradication
Permanent reduction to zero of the worldwide incidence of infection caused by a specific agent as a result of deliberate efforts; intervention measures are no longer needed. Example: Smallpox
Miller M. et al. In Disease Control Priorities in Developing Countries: 2nd Edition 2006

7. Feasibility Criteria for Elimination
In General1
Hepatitis C Virus
Check list
No non- human reservoir and the organism can not multiply in the environment
No human reservoir
There are simple and accurate diagnostic tools
Serology widely available
Practical interventions to interrupt transmission
Treatment as prevention
Needle exchange programs
Opioid substitution programs
The infection can in most cases be cleared from the host
Treatment is 95 % curative
1. Hopkins DR NEJM ;1

8. Essential Goals to Eliminate HCV
Prevent sequelae of advancing liver disease in those already infected
Baby Boomers, born
Prevent new or “incident” infections
Persons who inject drugs
Unsafe healthcare practices
Sexual exposures in Immunocompromised individuals

9. Cherokee Nation Jurisdiction
Sovereign Nation within a Nation
Oklahoma
14 county area (over 9,200 sq mi.)
Largest tribal operated health system (U.S.)
Second largest Indian Nation in the U.S.
322,855 Registered citizens world-wide
Medically serves 130,000 AI/AN
AI/AN: American Indians/ Alaskan Natives

10. Cherokee Nation Jurisdiction
Rural area with high HCV prevalence
130,000 AI/AN
80,928 citizens ages 20 – 69
HCV program since in 2012
ECHO model for delivery of HCV care
Clear pathways for medication procurement
Source: Cherokee Nation, 2017

11. CNHS HCV Clinic
262 HCV infected patients waiting to be treated
Prevalence unknown, possibly 5.8 %
Possibly 3,285 patients!!!!!!
How do we increase screening?
How we do we engage and treat more patients?

12. Hepatitis C Screening Electronic Health Reminders Work!!!!!!

13. Moving Knowledge Instead of Patients
GOALS:
Develop capacity to safely and effectively treat HCV in all areas and to monitor outcomes
Develop a model to treat complex diseases in rural locations and developing countries

14. HCV Services Available at CNHS 1/2012 -6/2014
HCV Clinics

15. HCV Services Available at CNHS 7/2014 – 7/2015
HCV Clinics

16. First ProjectECHO HCV Team
2014

17. CNHS HCV Elimination Program Goals 8/2015 – 10/2018
Secure political commitment for HCV elimination
Expand the HCV screening program
Establish robust programs to link to care, treat, and cure patients with HCV.
Reduce the incidence of new HCV infections
These goals were pre-implementation goals from over 1 year ago and they still hold true today
CNHS: Cherokee Nation Health Services

18. Goal #1: Political Commitment October 30, 2015, CNHS HCV Awareness Day
We knew within our tribal community that we would need public support and visible community awareness --- there would have to be tribal government officials who vocally supported our cause in order for us to build the infrastructure needed to meet our program goals.
“As Native people and as Cherokee Nation citizens, we must keep striving to eliminate hepatitis C from our population.” Chief Bill John Baker

19. Goal #2: Expand Screening Program
of Target Population
(80,928 AI/AN)
Universal Screening
Ages 20-69
Non-Traditional Screening Sites
Emergency Department
Urgent Care
Dental Clinics
Behavioral Health
OBGYN
Screening Modalities
EHR Reminders
Rapid Tests
Lab Triggered screening
Cherokee Nation Health Services

20. HCV Screening in CNHS* 10/2012 – 6/2017
Pre-elimination Period (10/2012-7/2015) 16,772 patients screened
Post-elimination Period (08/2015-6/2017) 31,399 patients screened
46 % of the target population has been screened
Primary Care
Urgent Care/Emergency/
Obstetrics/Dental/
Behavioral health
Number of Patients Screened
Universal Screening
Ages 20-69
Primary Care
Birth Cohort + Risk
In August of 2015 we started our HCV elimination program, and on that same month Cherokee Nation Health Services changed electronic health records (EHR) system. HCV screening data of those patients screened for HCV before the EHR was switched was not carried over to the new EHR, so many patients were screened again. That is why the sum of the number of patients screened before and after elimination started (08/2015) is 48,171 but the number of UNIQUE patients screened since 2012 is 37,122 patients, which represents 46 % of our target population (patients years old)
CNHS: Cherokee Nation Health Services
*preliminary data

21. HCV: Prevalence and Age Distribution
HCV: Prevalence and Age Distribution* Post Elimination Period, 8/2015 – 5/2017
Prevalence
Age Distribution of
HCV Ab (+) patients
31,399 patients screened
1,076 HCV seropositive
Overall Prevalence ~ 3.4%
Male 4.4%
Female 2.9%
Baby boomers
3.7% (12,540)
Younger than Baby Boomers
3.3% (18,319)
*preliminary data

22. HCV Screening in Cherokee Nation* 8/2015 – 5/2017
Expanded Age Targeted Screening (Ages 20-69)
Lab Triggered
Screening discontinued
Number of Patients Tested Per Month
Lab Triggered
Screening Initiated
*preliminary data

23. HCV “Lab Triggered” Screening* WW Hastings Hospital
*preliminary data

24. Lab Triggered Screening: Location Where Patients Were Screened
97 patients with new HCV antibody screen at WW Hastings Hospital

25. HCV Screening in the Hospital Dental Clinic*
AWARENESS AND ENGAGED IN CARE STATUS AT THE TIME OF SCREENING IN THE DENTAL CLINIC N=36
NUMBER OF PATIENTS SCREENED FOR HCV IN THE DENTAL CLINIC, MARCH 2016 – FEB 2017
Cherokee Nation Health Services
*preliminary data

26. Goal #3: Link to Care, Treat, and Cure
Evaluate 85%
Treat %
Cure %
Expand Clinical Capacity
ProjectECHO
Expand Case Management
Medication procurement
Patient navigator
Clinical case manager
READ TITLE: Once patients were screened, we had to have an efficient system to evaluate them clinically and we felt like we could do this by centralizing the screening reporting and assigning the tracking of those patients to specific work group members to decrease our lost to follow up rates. Some things we could implement to help in this effort were the use of rapid screening tests in which we could get a screening result in 20 minutes and immediately get the patient an appointment with one of our Hepatitis C providers. We also planned to expand the ECHO program to increase our coverage in the outlying clinics --- on a side note, we now have 12 PCPs and 8 pharmacists within our system treating hepatitis C with the support of the ECHO model. Expanding case management services was also a must. With the processes in place for procuring medications and then the close follow-up these patients would require, we had to increase our case manager work force. So we developed a measureable goal to treat 85% of patients in 3 years and cure 85% of those treated.
Cherokee Nation Health Services

27. HCV Services Available at CNHS 8/2015 – 9/2017
HCV Clinics

28. CNHS HCV Program: Clinical Capacity Expansion* 1/2014 – 6/2017
HCV ProjectECHO
Introduced
HCV Elimination
Started
1 Specialist
2 Physicians
2 APRN
2 Pharmacists 7
1 Specialist
6 Physicians
5 APRN
8 Pharmacists 20
Number of Patients Treated
1 Specialist
*preliminary data

30. Treatment Group Characteristics*
No Difference in HCV Cure Rates between Provider Types at CNHS (n= 365)
Specialists are almost as good as primary care providers
56 %
30 %
14 %
Cherokee Nation Health Services
*preliminary data

31. CNHS HCV Cascade of Care* 10/2012 - 6/2017
100 %
65 %
65%
51%
78%
64%
32 %
90% of patients who have completed treatment have achieved cure
*preliminary data

32. Goal #4: Reduce the Incidence of New HCV Infections
These goals were pre-implementation goals from over 1 year ago and they still hold true today
(Not Implemented)
Cherokee Nation Health Services. PWID: People Who Inject Drugs
OST: Opioid Substitution Therapy, NSEP: Needle and Syringe Exchange Program

33. Public Campaign September 20, 2016 - September 28, 2016.
Advertisement
Gas pumping
Indoor advertisement
Radio advertisement
Digital marketing
Social media

34. Out-of-Home Advertising

35. Provider Education HCV Providers All providers
University of Washington HCV Website
½ day Preceptorship at the hub HCV clinic
Shadowing the provider on their first day of HCV clinic
Biannual workshops in the 8 outlying clinics
Bimonthly HCV projectECHO telehealth clinics
All providers

36. CNHS Buprenorphine Clinic*
Buprenorphine Clinic started in March 2016 with 2 prescribers currently managing ~ 40 patients each
Drop out rate has been < 10 % since March 2016
No Emergency Department (ED) visits or hospitalizations due to buprenorphine misuse
No ED visits or Hospitalizations for opioid overdose in patients managed with buprenorphine
Cherokee Nation Health Services
*preliminary data

37. Distribution of HCV Among Young Persons and Location of Syringe Service Programs
Of 29,382 persons yrs. with HCV, 20% lived within 10 miles of a syringe service program.
1 dot = 1 person
Syringe Service Program
HCV Cases: LabCorp and Quest commercial laboratories SSPs: North American Syringe Exchange Network
The first order of business for preventing new HCV infections is improving access to safe injections. Syringe Service Programs and Medication Assisted Treatment have been shown to encourage safe injection practices. In fact, a new Cochrane systematic review demonstrates that SSP and MAT jointly decrease risk by 71%. But the US has a great deal of work to do in this regard. In a recent analysis now accepted for publication, Lauren Canary and others in my group used commercial lab data to map the locations of young persons with a positive tests for HCV RNA and the locations of local syringe service programs. As you can see, there is a great disparity in where young persons with HCV reside and their proximity to these services.
Canary L, Hariri S, Campbell C, et al. “Geographic disparities in access to syringe service programs among young people with hepatitis C virus infection in the U.S.” November CID, in press

38. How are we doing with our 85% Goals?
08/2015
10/2018
85%
Percentage

39. Moving Forward Advocate for NSEP Expand OST to all CNHS clinics
Increase public awareness
Intensify HCV screening in “hot spots”
Engage and retain in care difficult to reach populations
Identify networks of transmission to implement focused interventions (GHOST program)
Adapt program goals to the newly defined recommendations for HCV elimination in the United States
Define measures to monitor program outcomes
HCV incidence
HCV related mortality
Cherokee Nation Health Services

40. Thank You