1. Getting by (with a little help from our friends)
Marjorie Hurie, RN, MS
Wisconsin Hepatitis C Coordinator
Good afternoon. As many of you know, I recently transferred from being the hepatitis B coordinator to the hepatitis C coordinator. While I loved my hepatitis B job, I decided to take the opportunity to work on a disease that seemed to be begging for attention. I came into the job thinking I knew a fair amount about hepatitis C. During the past three months I’ve learned much more and I am very pleased to be here today to share a some of it - but not all of it, don’t worry. To that end, you have two handouts today. One is of the slides I will use and the other is a draft of Hepatitis C Guidelines for Local Health Departments that I have been developing. If you don’t see the specifics of the information I’m covering today in the slides, you’ll find it in the Guidelines.

2. Organization Chart & Authority
Division of Public Health
Bureau of Communicable Diseases
AIDS/HIV
STD
General Epi
Immunization TB
This organization chart will give you a picture of where hepatitis C is located in the Wisconsin Department of Health and Family Services. The Bureau of Communicable Diseases is one of 6 Bureaus in the Division of Public Health. There are 5 sections in the Bureau: AIDS, STD, General Epi, Immunization and TB. Hepatitis C is a program within the AIDS/HIV Section. This is a good place for a hepatitis C program to be, not only because of the similarities between the two diseases,
Hepatitis C is reportable by state statute and administrative rule to the local health department that has jurisdiction over where the patient lives. When patient follow-up is complete, LHDs forward the case reports they have received from providers and hospitals to the Hepatitis C Program.
Hep C

3. Hepatitis C Coordinator Responsibilities
Developing HCV testing capacity
Identifying sources of vaccine
Integrating HCV testing in high risk settings
Identifying medical resources
Educating providers and the public
This is an overview of what we are going to be discussing today: Wisconsin’s hepatitis C morbidity - as much as we know of it - ; serological patterns showing what happens when the patient does and does not clear the virus; an algorithm showing the natural history of hepatitis C, some characteristics of the hepatitis C virus such as infectivity and viability, the state role and the local role in the prevention, detection and management of hepatitis C; and resources for HCV care and treatment.

4. Approaches Rely on relationships Know and use the infrastructure
Obtain additional funding
Win, or be blessed by, support from administrators

5. Rely on relationships: Vaccine
Collaboration with the State Immunization Program
LHDs and CHCs can order hepatitis A and B vaccine for persons with HCV infection who are un-or under-insured for vaccine
Number of doses of adult Hep A vaccine shipped in 2002: 763
You are probably all familiar with the persons who should be screened for hepatitis C - for example, persons who have a history of injecting drug use, even if it was a few times many years ago, persons who had a transfusion before 1992, sex partners of hepatitis C positive persons and so forth. A complete list of persons who should be screened for hepatitis C is in the Guidelines. Local health departments can screen people for hepatitis C if they have one or more risk factors and are uninsured or have insurance that will not cover the cost of screening. LHDs that do not provide venipuncture should consider developing a relationship with a local provider to draw the blood. The specimen can be submitted to the state lab for hepatitis C testing under the LHD’s fee-exempt number. To maximize case-finding, LHDs should work with local substance abuse service providers that treat injecting drug users to develop anti-HCV testing services for their clients. For example, the Madison City health department offers hepatitis C screening to clients of a methadone maintenance facility. Positive EIA test results should be supplemented with a RIBA or confirmed with a PCR, as the following algorithm will show. The State lab offers PCR but not the RIBA test.

6. Know and use the infrastructure: Testing Capacity
WSLH performs hepatitis C EIA and qualitative PCR tests
Established system to pay for public health testing with state funds through an agreement between the Division of Public Health and the Wisconsin State Lab of Hygiene (SLH)
LHDs can test persons with HCV risk factors who could not otherwise access testing
LHDs can use MOUs to permit other health care providers, e.g., CHCs, to access testing thru SLH

7. Know and use the infrastructure: Testing in Corrections
History of collaboration on communicable disease issues with BCD and SLH
Regular quarterly meetings
All inmates screened for anti-HBc since 1980s
1999 serosurvey of incoming inmates identified selective HCV screening criteria

8. Current testing volume: 7/1/02-12/31/02
Dept of Corrections
EIA: N=988, +=315 (32%)
PCR: N=425, +=320 (75%)
LHDs and CHCs
EIA: N=260, +=48 (18%)
PCR: N=43, +=26 (60%)

9. Obtain additional funding: Hepatitis Plan
Wrote a successful proposal to CSTE
Identified and met with 32 external and internal experts 3 times
Drafted the plan
Implementation sections for hepatitis A, B and C
Overarching activities: surveillance, vaccination, provider education
Revising plan based on comments received
Distribution plans: printing, mailing, internet posting, state hepatitis conference

10. Support from Administration
AIDS/HIV Medical Director Jim Vergeront supportive and invested in success
Supervisors encourage collaboration among staff
Culture of collaboration is formalized by including collaboration with Hep C activities in AIDS/HIV staff PPDs (performance planning and development tool)

11. Support from Administration: Identifying medical resources [Adding HCV medications to AIDS Drug Assistance Program (ADAP)]
Estimated number of co-infected persons eligible for ADAP (a few)
Obtained drug cost information from MA($$$)
Calculated costs ($200,000)
Determined what other states had done
Obtained opinions from ADAP’s external medical advisors
Received permission, announced availability

12. Support from Administration: Integrating HCV Testing into HIV CTR sites
Preplanning integration with AIDS/HIV CTR staff
HIV anonymity limited extent of integration (forms, reports)
Developed model procedures for HCV testing counseling and referral
Presented integration overview at regional CTR meetings

13. Support from Administration: Educational Materials
Developed by Knupp and Watson (graphic design company)
Intended audience: public and private clinics, local health departments
Purpose: inform about prevention, risk factors and encourage testing
Funding: One time use of discretionary state funds for HIV

14. Poster

15. Brochure

16. Caveats
If relationships are not good,
If you don’t know the infrastructure,
If you don’t get extra funding,
If management is not inclined or able to be supportive,
Getting stuff done will be more difficult

17. But there are limits to largesse….
Milwaukee STD program did not continue HCV testing after completion of pilot because following up + test results took too much staff time
Some LHDs and HIV CTR sites are unwilling to integrate HCV testing without a per capita payment for clients tested

18. Approximate value of contributed goods and services: 2002
Vaccine (Hep A) $20,000
Vaccine (Hep B) $28,000
Testing $100,000
Education materials
Development $5,000
Printing $2,000
$155,000

19. Poster and brochure instructions
Printer Disc
Cannot be read with regular software
Printer can change text
Handout includes printer specifications
To customize
Mark up paper copy with desired changes
Ask printer to make changes and give back proofs