1. Scioto County Medical Society Grand Rounds March 31, 2006 Portsmouth, Ohio Kathleen M. Koechlin, RN, MPH, PhD Hepatitis C Coordinator The Ohio Department of Health kathleen.koechlin@odh.ohio.gov

2. The Epidemiology of Hepatitis C Worldwide: Worldwide: Approximately 180 million people (3.0% of the world population) are infected with HCV. Approximately 180 million people (3.0% of the world population) are infected with HCV. Approximately 130 million are chronic carriers. Approximately 130 million are chronic carriers. Approximately 3-4 million people are newly infected each year. Approximately 3-4 million people are newly infected each year. 70% of these will develop chronic HCV. 70% of these will develop chronic HCV. HCV is responsible for 50-76% of all liver cancer cases and 2/3 of all liver transplants in the developed world. HCV is responsible for 50-76% of all liver cancer cases and 2/3 of all liver transplants in the developed world.

3. Countries with low disease prevalence (<1%): Countries with low disease prevalence (<1%): Australia Australia Canada Canada Northern Europe Northern Europe Countries with moderate disease prevalence (around 1%): Countries with moderate disease prevalence (around 1%): United States United States Europe Europe Countries with high disease prevalence (>2% and many times as high as 5-10%): Countries with high disease prevalence (>2% and many times as high as 5-10%): Africa Africa Latin America Latin America Central and Southeastern Asia Central and Southeastern Asia Countries with extremely high disease prevalence: Countries with extremely high disease prevalence: Nile delta of Egypt (up to 60% in 30 year olds) Nile delta of Egypt (up to 60% in 30 year olds) http://www.who.int/vaccine_research/diseases/viral_cancers/en/inde x2.html#disease%20burden

4. Hepatitis C Virus Infection, United States New infections per year 1985-89242,000 2001 25,000 Deaths from acute liver failureRare Persons ever infected (1.8%)3.9 million (3.1-4.8)* Persons with chronic infection2.7 million (2.4-3.0)* HCV-related chronic liver disease40% - 60% Deaths from chronic disease/year8,000-10,000 *95% Confidence Interval

5. Hepatitis C in Ohio

6. The hepatitis registry was established in 2001 using tobacco industry settlement funds. The hepatitis registry was established in 2001 using tobacco industry settlement funds. The purpose of this registry is to provide population based data that accurately describes hepatitis C in Ohio. The purpose of this registry is to provide population based data that accurately describes hepatitis C in Ohio. This information is used to target resources for planning and evaluating hepatitis prevention, treatment, and service programs in the state. This information is used to target resources for planning and evaluating hepatitis prevention, treatment, and service programs in the state.

7. Every Ohio county has reported at least one hepatitis C diagnosis. Every Ohio county has reported at least one hepatitis C diagnosis. As of September 30, 2005, the hepatitis registry contained over 48,000 cases, of which just under 40.0% are confirmed hepatitis C diagnoses. The other 60.0% are potential diagnoses that are being investigated. As of September 30, 2005, the hepatitis registry contained over 48,000 cases, of which just under 40.0% are confirmed hepatitis C diagnoses. The other 60.0% are potential diagnoses that are being investigated. Approximately 500 reports of potential hepatitis diagnoses are received by hepatitis surveillance each week. These reports include new cases and updates to cases under investigation. Approximately 500 reports of potential hepatitis diagnoses are received by hepatitis surveillance each week. These reports include new cases and updates to cases under investigation.

8. Of all cases in the hepatitis registry, 64.8% are male, and 59.2% are ages 40 to 59 years. Of all cases in the hepatitis registry, 64.8% are male, and 59.2% are ages 40 to 59 years. Nearly 70% of reported hepatitis cases are lacking race information. Nearly 70% of reported hepatitis cases are lacking race information. Quarterly and annual summary statistics are compiled from the cleaned data and released for public use on the ODH website. Quarterly and annual summary statistics are compiled from the cleaned data and released for public use on the ODH website.

9. Challenges in Reporting Demographic information Demographic information Source: ODH Hepatitis Surveillance Program.

10. Challenges in Reporting Risk factor information Risk factor information Source: ODH Hepatitis Surveillance Program.

11. Importance of Complete Reporting Determine who is at risk Determine who is at risk Allocation of public health dollars Allocation of public health dollars Targeted prevention programs Targeted prevention programs Examine trends in the epidemic Examine trends in the epidemic Geography, race, sex, age Geography, race, sex, age Data analysis Data analysis Determining if prevention efforts succeed Determining if prevention efforts succeed Providing information to health departments, organizations, educational programs Providing information to health departments, organizations, educational programs Source: ODH Hepatitis Surveillance Program.

12. Know your ABCs Class A Diseases Class A Diseases (1) diseases of major public health concern because of the severity of disease or potential for epidemic spread; report by telephone immediately ex: Plague (1) diseases of major public health concern because of the severity of disease or potential for epidemic spread; report by telephone immediately ex: Plague (2) diseases of public health concern needing timely response because of potential for epidemic spread- report by the end of the next business day ex: Hepatitis A (2) diseases of public health concern needing timely response because of potential for epidemic spread- report by the end of the next business day ex: Hepatitis A (3) diseases of significant public health concern; report by the end of the work week ex: Hepatitis B, C, D, E (3) diseases of significant public health concern; report by the end of the work week ex: Hepatitis B, C, D, E Class B Diseases Class B Diseases Report by end of work week ex: influenza Report by end of work week ex: influenza Class C Diseases Class C Diseases Report outbreak or unusual incidence by end of next working day ex: Toxoplasmosis Report outbreak or unusual incidence by end of next working day ex: Toxoplasmosis Source: ODH Hepatitis Surveillance Program.

13. Hepatitis C in Ohio Health statistics can be found on the ODH website, http://www.odh.ohio.gov Health statistics can be found on the ODH website, http://www.odh.ohio.gov http://www.odh.ohio.gov -Click on Health Statistics → Infectious Diseases → Reported Cases of Selected Notifiable Diseases- Ohio → Choose the year you are interested in reports available by year and month of report, patient age, gender, and county of residence reports available by year and month of report, patient age, gender, and county of residence Source: ODH Hepatitis Surveillance Program.

14. Describing Hepatitis C in Ohio Source: ODH Hepatitis Surveillance Program.

15. Hepatitis C (past or present) in: 20032004 1st Quarter 2005 Adams County340 Jackson County936 Lawrence County20218 Pike County954 Ross County171520 Scioto County5815641 Ohio451654262470

16. Chronic hepatitis C reported to CDC by Ohio in 2004* *Numbers may be incomplete due to underreporting, reporting delays, and/or missing information Source: Ohio Department of Health Hepatitis Surveillance Program

17. The Ohio Department of Health HIV/HCV Integration Project Why integration????

18. The Ohio Department of Health HIV/HCV Integration Project The Ohio Department of Health HIV/HCV Integration Project Study Inception: May 2003 Study Inception: May 2003 Location: 15 HIV Counseling and Testing Sites throughout the state (will have 16 by the summer 2006) Location: 15 HIV Counseling and Testing Sites throughout the state (will have 16 by the summer 2006) Population: Individuals who seek HIV testing Population: Individuals who seek HIV testing Inclusion criteria: Presence of at least one of listed risk factors for HCV Inclusion criteria: Presence of at least one of listed risk factors for HCV Exclusion criteria: Insistence on anonymous testing Exclusion criteria: Insistence on anonymous testing

19. Site # of anti-HCV tests # of positive anti- HCV tests (%) Total tested who were confirmed positive for HCV (%) AVOC82 (25.0) Allen County19511 (5.6)10 (5.1) Canton City494 (8.2) Columbus City47159 (12.5)49 (10.4) Erie County342 (5.9)1 (2.9) Free Medical Clinic of Cleveland18717 (9.1)14 (7.5) Highland County Health Dept.83 (37.5)1 (12.5) J. Glen Smith Health Ctr68127 (4.0)18 (2.6) Mansfield/Richland County7910 (12.7) Meigs County Health Department40 (0.0) Newark City33830 (8.9)26 (7.7) Portsmouth City27833 (11.9)25 (9.0) Thomas McCafferty Health Ctr120836 (3.0)26 (2.2) Washington County987 (7.1)6 (6.1) Youngstown City141 (7.1)0 (0.0) Total3652242 (6.6)192 (5.3) Summary of HCV Testing: 2005

20. Some words about risk assessment…….

21. ODH Hepatitis Contacts: Surveillance/ODRS: Surveillance/ODRS: Jessica Lietz, MPH 614-728-6975 Richard Thomas 614-644-1852 Perinatal Hepatitis B: Perinatal Hepatitis B: Ann Richardson, RN 614-995-1874 Hepatitis C Coordinator Hepatitis C Coordinator (also can answer clinical questions): Kathleen Koechlin, RN, MPH, PhD 614-644-2714

22. Questions?????