1. HCV epi overview Brigg Reilley, NPAIHB,
Nat’l Program Epidemiologist,

2. In 20 minutes, we will cover
Transmission/trends
Screening
HCV estimates: national, IHS, OK (federal), Cherokee

3. Disclosures
My powerpoint formatting skills are truly apalling

4. Risk Factors for Transmission of Hepatitis C
Injection Drug Use
Blood Products
Male-Male Sex
Mother to Child
Heterosexual Sex
68% IDU
18% sexual
9% unknown
4% occupational
1% other
Needlestick Injury

5. Hepatitis C Prevalence (NHANES estimate)
3.2 Million HCV Antibody positive
Possibly up to 7.1 Million HCV Antibody positive in US
Armstrong GL, et al. Ann Intern Med. 2006;144: ; Chak E, et al. Liver Int. 2011;31:

6. Knowledge of HCV Infection Unaware of HIV infection 21%
NHANES Survey, United States, Awareness of HCV Infection Status
Knowledge of HCV Infection
Unaware of HIV infection 21%
Other surveys have even more disappointing results:
Smith B et al MMWR 2012; 61 (RR-4): 1-32
45-85% unaware of their status
Among high-risk populations, testing rates are 17%-87%
~70% of IDU’s witih HCV are unaware of their status
Reasons Why:
No insurance, limited access to care, accuracy of pt recall of risk, patients uncomfortable disclosing risk factors, time constraints, provider reluctance
Source: Denniston M, et al. Hepatology. 2012:55: 1

8. NHANES Survey: United States, 1988-1994 and 1999-2002 Prevalence of HCV Antibody, by Year of Birth
HCV Prevalence(%)
1910
1988–1994
1999–2002
7.0
6.0
5.0
4.0
3.0
2.0
1.0
1920
1930
1940
1950
1960
1970
1980
1990
Priority populations: baby boomers (born ) currently aged 45-65
Baby Boomers have a HCV infection rate of 1 in 33 (3%)
Still about 20,000 new infections per year, mainly in IDU population
Source: Armstrong GL, et al. Ann Intern Med. 2006;144:

9. A 300% Increase in Hepatitis C –related Hospitalization for AI/AN – 1995-2007
Byrd KK, et al Pub Hlth Rep 2011

10. HCV related mortality (CDC National Surveillance data, 2016)
Rates nationally and among AI/AN dropped slightly from
But rates remain the highest of all race ethnicities by far and double the national rate (10.75/100,000 among AI/AN, 4.45/100,000 nationally)

12. OSDH recommends testing for the following persons:
Anyone born from 1945 through 1965.
Anyone who has injected drugs, even just once or many years ago.
Anyone with certain medical conditions, such as chronic liver disease and HIV or AIDS.
Anyone who has received donated blood or organs before 1992.
Anyone with abnormal liver tests or liver disease.
Anyone who has been exposed to the blood from a person who has Hepatitis C.
Anyone on hemodialysis.
Anyone born to a mother with Hepatitis C

14. OK state data, 2015 acute HCV
In 2015, a total of 92 cases reported and confirmed as acute HCV in Oklahoma.
53.3% of these cases were among males, while 46.7% were females.
Age group years of age had the most cases and highest rates of all the diagnosed acute cases (21.7%).
Whites made up 56.5% of the acute HCV cases were White.
80.3% of acute HCV patients reported having two or more sexual partners, while 62.5% reported using needles for street drugs

15. Chronic Hepatitis C Infection Disproportionately Affecting Oklahomans; OSDH Encourages Testing For Release: April 26, 2017
According to a newly released study, there are an estimated 94,200 Oklahomans living with Hepatitis C virus infection. Estimates were developed by researchers at Emory University in conjunction with the Centers for Disease Control and Prevention to better understand the number of people in each state living with Hepatitis C.
The Oklahoma State Department of Health (OSDH) is encouraging residents to be tested for the virus as Oklahoma had the highest estimated prevalence in the nation at 3.34 percent, while the national prevalence was 1.67 percent. The report also indicates 523 Oklahomans died due to Hepatitis C from , ranking our state among the highest for Hepatitis C mortality.

16. Recommended Testing Sequence for Identifying Current Hepatitis C Virus (HCV) Infection-
HCV antibody +
Nonreactive
Reactive -
HCV RNA
Not detected +
Detected
No HCV antibody detected
No current HCV infection
Current HCV infection
STOP*
Additional testing as appropriate†
Link to care
* For persons who might have been exposed to HCV within the past 6 months, testing for HCV RNA or follow-up testing for HCV antibody is recommended. For persons who are immunocompromised, testing for HCV RNA can be considered.
† To differentiate past, resolved HCV infection from biologic false positivity for HCV antibody, testing with another HCV antibody assay can be considered. Repeat HCV RNA testing if the person tested is suspected to have had HCV exposure within the past 6 months or has clinical evidence of HCV disease, or if there is concern regarding the handling or storage of the test specimen.
Source: CDC. Testing for HCV infection: An update of guidance for clinicians and laboratorians. MMWR. 2013;62(18).
Slide courtesy AASLD Curriculum & Training

17. HCV Screening 2012-2017, IHS federal sites, persons born 1945-1965
OK SUs 62%
Tribal sites lower nationally

18. Universal HCV Screening, Cherokee Nation
From 8/16-12/17, the program screened 38,591 persons ages for HCV HCV Ab+ test reflexes to RNA confirmation

19. By Age Category (CNHS)

20. By Sex (CNHS)

21. HCV new diagnoses, IHS data

22. IHS HCV new dx by age group, 2005-2015, national
Age (Years)
Number (rate per 100,000) 
<15
150 (3.3)
15-24
2,085 (67)
25-39
8,302 (235)
40-54
14,234 (496)
55+
5,032 (199)

23. IHS new HCV dx by birth cohort, 2005-2015, national
 Number (rate per 100,000)
Born Before 1945
1,118 (101)
Born
(Baby Boomers)
15,900 (478)
Born After 1965
12,785 (105)

24. IHS new HCV dx by sex, 2005-2015, national
No. (Rate/100,000)
Sex
Male
15,362 (193)
Female
14,441 (166)

25. IHS new HCV dx by region 2005-2015, (national data)
Number (rate per 100,000) 
Rate Ratio, 95% Confidence Interval 
P value 
Alaska
2,743 (179)
0.81 ( )
<0.0001
East
1,051 (197)
0.89 ( )
0.0005
Northern Plains East
1,875 (166)
0.75 ( )
Northern Plains West
4,801 (224)
1.01 ( )
0.4462
Southern Plains
7,986 (221)
Reference
Southwest
5,538 (98)
0.44 ( )
West
5,809 (286)
1.29 ( )
Total
29,803 (179)

26. Cascade of Care, OK sites

27. Site 1
Site 2
Site 3
Site 4
Psite 5
Site 6
Site 7
Site 8
Comments
HCV Ab+
800
323 79
181
233
136 16
1768
Ab+, RNA neg
172
101 5 17
110 46 1
452
No further clinical follow up needed
Ab+, RNA unk
228 57 30 50 7 6
378
Need RNA testing
RNA +
400
160 44
114
144 60
929
Need to be cured
RNA+ and Metavir 3-4 76 4 2 11
137
Late stage disease need treatment ASAP
RNA+ and Metavir 0-2
230
111 15 65 13
439
RNA+ and Metavir unk 94 25 47 36
353
Need to have metavir calculated
Currently in tx 8
Treatment complete, SVR
106 48
Cured. Excellent numbers
Treatment complete, SVR pending 18 23 3

28. Summary
OKC Area is doing well overall compared to other Areas, but each site needs support to address gaps in the Cascade of Care, namely
Linking HCV patients to care for RNA testing and Metavir scoring
Increasing number of HCV patients in treatment to cure existing patients in a timely manner

29. Barriers ranked by SUs
SUs cited the main barriers to increasing HCV services as 1) needing more time to work on HCV clinical services, 2) contacting historical HCV patients to return to care for confirmation or treatment, and navigating the drug acquisition process.