1. Stacey B Trooskin MD PhD.
Stacey B Trooskin MD PhD
C a Difference aims to better understand the needs of HCV positive patients participating in clinical and community based HCV testing programs.

2. Clinical Testing
Community Testing

3. Epidemiology of HCV in the US
Most common blood-borne infection in the US
3.2 million to 5.2 million persons chronically infected
Birth cohort : 3.27% antibody positive
Non-Hispanic blacks: 6.31%
Non-Hispanic whites: 2.92%
Mexican American/ other: 2.78%
50% to 75% of individuals chronically infected with HCV are unaware of their infection
Much of what we know about HCV in the US comes from NHANES- a study which includes non institutionalized US civilians
Chak E. Liver Internat. 2011, 2:
Smith BD. AASLD poster #394, 2011
Armstrong GL. Annals of Int Med, ; 

4. Natural History of HCV Infection
75-85%
Acute
HCV
Chronic
HCV
Hepatic
Inflammation
Alcohol, HIV, and hepatitis B may accelerate fibrosis
15-25%
Hepatic
Fibrosis
Spontaneous
Resolution
20% in 20 yrs
Cirrhosis
2 – 4% per yr
2 – 5% per yr
Hepatocellular
Carcinoma
Hepatic
Decompensation
Seeff LB. Hepatology 2002;36 (Suppl 1):S35-46.

5. Treatment cascade for people with chronic HCV infection
Yehia B. PLoS One. 2014; 9(7) e

6. Sources of Infection for Persons with Newly Diagnosed HCV
Unknown 10%
Other 5%
Transfusion
prior to 1992
10%
Sexual 15%
CDC, National Hepatitis C prevention strategy 2001.

7. Seroprevalence of HCV: 170M to 200M worldwide
JP Messina et al. Hepatology. 2015; 61(1):77-87.

8. CDC Recommendations for HCV testing
Birth Cohort based screening
All individuals born between 1945 and 1965 should be tested at least once for HCV
All individuals outside of this cohort with a HCV risk factor should be screened
Cost-effective
1-time cohort screening would identify about 86% of undiagnosed cases, compared with 21% with risk-based screening
US Preventive Services Task Force: Grade B recommendation
Will mention work with prevention point here to the first bullet point:
CDC. MMWR 2012;61(No. RR-4).
Rein DB. Ann Intern Med. 2012;156(4):263-70

9. Recommended testing sequence for identifying HCV infection
Options for confirmatory testing
Subsequent venipuncture is submitted for HCV NAT if the blood sample collected is reactive for HCV antibody during initial testing.
From a single venipuncture, two specimens are collected in separate tubes: one tube for initial HCV antibody testing; and a second tube for HCV NAT if the HCV antibody test is reactive.
The same sample of venipuncture blood used for initial HCV antibody testing, if reactive, is reflexed to HCV NAT without another blood draw for NAT (13).
A separate venipuncture blood sample is submitted for HCV NAT if the OraQuick HCV Rapid Antibody Test for initial testing of HCV antibody has used fingerstick blood
CDC. MMWR 2013; 62(18)

10. 2̊ Prevention: Counseling our patients
Limit acetaminophen < 2 grams/day
Avoid ingestion of raw seafood
Vibrio vulnificus & Vibrio parahaemolyticus infection
Maintain BMI < 25 kg/m2
Avoid iron supplements, unless documented deficiency
Immunizations/ management of HBV coinfection
Formal reevaluation yearly for consideration of HCV treatment
repeat fibrosis staging at 2-4 year intervals
Abstain from alcohol use
Sulkowski MS et al. USDHHS/HRSA:

13. Impact of HCV Testing Prompts on Type of HCV Screening Test Ordered

14. Percentage of Eligible Baby Boomers Tested Before and After Prompts Went Live

15. Provider receives confirmatory test results
Notifies Linkage Coordinator
Linkage Coordinator calls patient with result
Provider calls patient with results
Insurance status assessed
Insured w/ PCP: Needs referral and HCV appointment
Uninsured: Needs to see Monique

16. How to Task CaD Linkage Coordinator
If possible, complete confirmatory testing before tasking Carla
Task Carla Coleman with positive HCV patients via Allscripts
Specify a preference for whether patient is referred to Hepatology or the Partnership Practice
Provide appropriate referrals and scripts for ultrasound if needed
Anything over a year old is out-dated