1. DISCLOSURES
This activity is jointly provided by Northwest Portland Area Indian Health Board and Cardea
Cardea Services is approved as a provider of continuing nursing education by Montana Nurses Association, an accredited approver with distinction by the American Nurses Credentialing Center’s Commission on Accreditation.
This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Institute for Medical Quality/California Medical Association (IMQ/CMA) through the joint providership of Cardea and Northwest Portland Area Indian Health Board. Cardea is accredited by the IMQ/CMA to provide continuing medical education for physicians.
Cardea designates this in-person training for a maximum of 7 AMA PRA Category 1 Credit(s)TM. Physicians should claim credit commensurate with the extent of their participation in the activity.  

2. DISCLOSURES COMPLETING THIS ACTIVITY
Upon successful completion of this activity 7 contact hours will be awarded
Successful completion of this continuing education activity includes the following:
Attending the entire CE activity;
Completing the online evaluation;
Submitting an online CE request.
Your certificate will be sent via If you have any questions about this CE activity, contact Michelle Daugherty at or (206)

3. CONFLICT OF INTEREST
None of the planners or presenters of this CE activity have any relevant financial relationships with any commercial entities pertaining to this activity.

4. Acknowledgement This event is funded in part by:
  This event is funded in part by:
The Indian Health Service HIV Program
and
The Secretary’s Minority AIDS Initiative Fund

5. Objectives
 By the end of this learning event participants will be able to:
Define elimination as it relates to infectious disease
Identify interventions required to achieve HCV elimination
Describe Lummi HCV elimination program

6. Starting a Hepatitis C Elimination Program at Lummi
Justin Iwasaki MD MPH
Executive Medical Director
Lummi Tribal Health Center

7. World Health Organization
Elimination
Reduction to zero of the incidence of disease or infection in a defined geographical area.
World Health Organization
HCV ELIMINATION

9. HCV is a Public Health Problem Requiring a Public Health Response
Treatment as Prevention
HCV ELIMINATION

10. Incidence of Acute Hepatitis C by Race/Ethnicity (USA)
Source: National Notifiable Diseases Surveillance System (NNDSS)

11. 80% of New HCV Infections Occur in People Who Inject Drugs (PWID)
Source: National Notifiable Diseases Surveillance System (NNDSS)

12. Super Infectors +Usual Infectors+Non-Infectors
HCV ELIMINATION

13. HCV Program Design Considerations
PWID May Not Fit the Usual Healthcare Delivery Model We Created
Scheduled Office Visits
Follow Up with Testing and Imaging and Future Appointments
Convenient Contact with Telephone or Mail
Reliable Transportation
Ability to Safely Store Medication
Predictable Changes to Home Life: Hospitalization, Incarceration, Drug/Alcohol Rehab
Family and Friend Support
HCV ELIMINATION

14. We Had to Create A New Model of Healthcare Delivery
HCV ELIMINATION

15. Cascade of Care Example from the University of BC
This is just an example from the Univeristy of British Columbia, but I like the simplicity. It is easy to model a database after, and to identify categories and trends. The goal of course being to reverse the chart, move the diagnosed patient population to the cured population. We have been attempting this by increasing Screening, community education, and we are working on developing more specific plans tailored to patients with less stable lifestyles.
Again remembering what works for one patient could be impossible to for another patient to adhere to
Example from the University of BC

16. Two Components of the Program
Getting the Patient Ready for Treatment
Treatment and Monitoring
HCV ELIMINATION

17. Getting the Patient Ready for Treatment
HCV Project Coordinator (RN) and Assistant
Initially, required multiple visits, could not get outside imaging, significant amount of human resources.
Partnered with NWPAIHB to Establish a Single Visit Ready to Treat Program
HCV ELIMINATION

18. Single Visit Ready to Treat Program
Day 0
Rapid HCV Ab Test
Positive
Negative
HCV RNA with Reflex to Genotype (standing orders)
BMP
LFT
INR
CBC
*Fibroscan
Re-Screen Based on Exposure History
Day 1
No Chronic HCV
Chronic HCV
Retest HCV RNA q6month
Present to Project ECHO
Submit Prior Authorization
4-6 Weeks
Start Treatment

19. Fibroscan: calculates liver stiffness based on sound wave.
Non-invasive Minutes.
RN, Rad Tech, MD
HCV ELIMINATION

20. Treatment and Monitoring Medication Compliance
Daily, Weekly, Bi-Monthly
Partner with Opioid Treatment Program
Home Visits and Outreach
HCV ELIMINATION

21. Lummi HCV Cascade of Care
74%
Number of Patients
I need the total number of unique patients tested in the time frame that the 366 patients were positive to estimate the seropositivity
73%
79%

22. Screened 1861 of 5775 Adult Patients for HCV
Initiating Treatment ~5 Patients Per Month
Eliminate HCV 2021*
HCV ELIMINATION

23. All Patients Care About Treatment
Untreated bipolar, homeless/living on sail boat,frequent drug use. YWCA, Shelter, ER.
Arrested Patient: “Not Without My Harvoni”
HCV ELIMINATION

24. Jessica Leston and David Stephens NWPAIHB
Thank You
Jessica Leston and David Stephens NWPAIHB
Dr. Jorge Mera
Jessica Rienstra HCV Project Coordinator
Kim Schiller HCV Project Assistant
HCV ELIMINATION