1. Perinatal Hepatitis C in Kentucky
Kathy J. Sanders, RN MSN
Kentucky Department for Public Health
Adult Viral Hepatitis Prevention Coordinator
December 2016
NASTAD Conference

2. Disclosures
Kathy Johnson Sanders, RN MSN and the Kentucky Department for Public Health have no relevant financial relationships with commercial interests to disclose.

3. Objectives
Background
Methods
Results
Discussion/Conclusions

4. Rates of Acute Hepatitis C Virus (HCV) Infections 2007-2013 http://www
Kentucky
West Virginia
Indiana
Kentucky, West Virginia, Indiana and TN in top four
COMPILED DATA FROM SOURCE:
States with consistent reporting (RATES ONLY)
Alabama
Arkansas
California
Colorado
Florida
Georgia
Idaho
Illinois
Indiana
Kentucky
Louisiana
Maine
Maryland
Michigan
Minnesota
Missouri
Nevada
New Jersey
New Mexico
New York
North Carolina
Ohio
Oklahoma
Oregon
Pennsylvania
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Tennessee

5. Incidence of acute hepatitis C among persons aged years, by urbanicity and year– Kentucky, Tennessee, Virginia, and West Virginia,
Non-urban
Urban
SOURCE:

6. Background
In 2012, Kentucky Adult Viral Hepatitis Prevention Program partnered with selected local health departments (LHDs) for HCV laboratory testing pilot project for individuals with identified risk factors
Results: Identified a large number of confirmed HCV-positive tests in the age group
Raised concerns about the potential for mother-to-child transmission of HCV
Over 8300 tested. 12% positive rate, 79% of positives reported history of IDU, 94.5% white non Hispanic. Interestingly, MSM represented 4.6% of those tested, yet only 2.2% of the MSM were HCV positive.

7. Methods
In late December 2013, DPH requested voluntary reporting from healthcare providers across Kentucky for:
All HCV-positive pregnant women
All infants born to HCV-positive women
All HCV-positive children aged 5 years or less
Reporting was mandated by law in Feb 2015

8. CDC- Top 220 US Counties http://www. kyrha
In early 2015, Scott County Indiana…..October 2015, the Dr. John Brooks CDC released the “Top 220 U.S. Counties with Increased Vulnerability to Rapid Dissemination of HIV/HCV Infections among IDU

9. CDC- 55 High Risk Counties in Kentucky
Fifty five counties of the 120 counties in Kentucky were identified as being high risk.

11. Mothers or Pregnant Women
Results: Dec 2013 to Nov 2016
 Age Groups
Cases
Mothers or Pregnant Women
1651
≤20 72
21-24
391
25-29
610
30-34
341
35-39
139
40+ 26
Unknown
Children
731
≤12 Months
325
>12 Months
360
unknown
Pregnant Women (n=1651) Children (n=731)

12. Results Mothers or Pregnant Women (n=1651) Age<18 months (n=579)
HCV RNA+
HCV RNA-
No HCV RNA
Total
HCV Ab+
222 58
1094
1374
HCV Ab- 1 4 5
No HCV Ab 64
207
272
287 59
1305
1651
 Age<18 months (n=579) 16 10 33 29 20
466
515 45 34
500
579
 Age ≥ 18 months (n=106) 13 22 39 9 7 3 48 79
106

13. Risk Factors of Mothers or Pregnant Women
Results
Risk Factors of Mothers or Pregnant Women
Yes
No/Unknown
% with risk factor
Intravenous Drug Use
608
1043
36.8%
Multiple Sex Partners
162
1489
9.8%
STD 59
1592
3.6%
HIV 5
1636
0.3%
Exposure to Known HBV/HCV Positive Contact 57
1594
3.5%
Foreign-Born 1
1650
0.1%
Incarceration ** 26
688
3.7%
** new data system Gentrack, now monitoring reported reports of incarceration

14. MMWR- Increased Hepatitis C Virus (HCV) Detection in Women of Childbearing Age and Potential for Vertical Transmission- United States and Kentucky,

15. Discussion
Results in MMWR indicated that from , HCV detection among women of child bearing age in Kentucky increased 213% from 275 to 862 per 100,000.
1 in 63 births in Kentucky
About 80% have current disease when HCV RNA is reported
Multiple risk factors are associated with pregnant women and mothers with HCV
Vertical transmission of HCV is occurring in Kentucky
Not limited to urban centers
MMWR Report:

16. Creating Outreach/ Awareness:
Healthcare systems throughout Kentucky
KY Maternal Child Health- Neonatal Abstinence Syndrome
KY Cabinet for Health and Family Services- Division of Protection and Permanency
Local Health Department (LHD)- Core Clinical Service Guide (CCSG) implementation of HCV testing and referral protocols
WIC Program
Well Child Visits-Documentation and reminders in the Electronic Medical Record
Flow Charts in the CCSG created for LHD screening, testing, and referral
* University of Kentucky not testing pregnant women coming in to labor, several reasons: not recommended by ACOG and these women are coming in to deliver and leaving AMA within 24 hours- reports showing moms delivering in woods, gas stations, hotels . We believe our data speaks for itself and warrants…Currently working with Commissioners office to add verbiage in regulations for all pregnant in KY women to be HCV tested.
* NAS became reportable in July 2014, working on cross analyzing data.- Working with commissioners office to add to regulations to add HCV antibody testing for newborn NAS. Louisville infant abandoned, mother injecting in ER- IV. Was not able to get babies history, so HCV tested.
* Training to foster families. Mandatory ATV training being produced.

17. LHD Guidance NAS became reportable in July 2014, cross analyzing data.

18. LHD Guidance NAS became reportable in July 2014, cross analyzing data.
Training to foster families. Mandatory ATV training being produced.

19. Conclusion Identified pregnant women are only the tip of iceberg
Lack of tailored education and awareness campaigns about HCV transmission, particularly in rural areas of the state, need to be implemented. Kentucky Public Health officials support increased surveillance of HCV- recently approved to receive ASTHO grant funds to develop a Kentucky Epidemiologic Profile
Legislation was passed in February to make perinatal HCV a reportable disease in KY, effective Feb 26, 2015
Recent approval (November 2016) in Legislature of amended form to report HCV in pregnant women, infants born to HCV-positive mothers, and HCV in children aged five years or less
Faxed reports are now being entered into a tracking system for analysis
Development of a Kentucky Hepatitis Position Statement
We need boots on the ground!
In the past, EPI info was used for data entry. Currently epidemiologists donated from other programs have assisted in entering and analyzing the data. With the GENTRACK system, LHD’s and birthing centers could enter their data into this system and track their regions/ centers perinatal data.
Emergency funds!!!

20. Limitations
Voluntary testing of high risk pregnant women- Not ACOG recommended
Post Partum Follow up of women identified as HCV positive, RNA confirmation and linkage to care
Incarcerated pregnant women
Need HCV test panel for pregnant women similar to HBV test panel
Follow up testing and monitoring of infants born to mothers with HCV infection- foster care, placement with family members
Data entry and analysis

21. Acknowledgements Co-authors Robert Brawley, MD, MPH, FSHEA
Hollie Sands, MPH
Tori Amburgey, MPH
Kentucky Department for Public Health, Division of Epidemiology and Health Planning
Kentucky Local Health Departments and Private Providers/ Birthing Centers who voluntarily reported in 2013 and 2014 and reported after law became effective in 2015

22. Kathy J. Sanders KathyJ.Sanders@ky.gov 502-564-3261 ext. 4236
Thank You
Kathy J. Sanders ext. 4236