A Walk in These Shoes: Eliminating Hepatitis C One

Step at a Time

2019 ILL INOIS REENTRY CONFERENCE

Objectives

1. Evaluate your role within HCV micro-elimination and personal action steps towards fulfilling that role

2. Assess your current practices and programs to identify opportunities and barriers to address HCV

3. Identify next steps, action plans, effective modifications and interventions to implement responsive HCV programs

Contact Information

Jill Wolf – Program Director

Jill@CaringAmbassadors.org - 503-632-9032 x 4

Dante Williams – Program Coordinator

Dante@CaringAmbassadors.org – 503-632-9032 x 5

WHAT IS HEPATITIS?

HAV HBV HGVHEVHDVOther:Alcohol, meds, toxins, etc.

Hepatitis =Liver inflammation

HCV

WHAT’S THIS HEPATITIS THING?

HAV HBV HCV

Transmission Fecal/Oral Blood & Body Fluid

Blood

% develop chronic infection

0% 6-10% 75-85%

Immunity after infection?

Yes Yes No

Vaccine? Yes Yes No

Cure? Yes/self-limiting No Yes

WHAT IS HEPATITIS C (HCV)?

• A blood-borne virus that affects the liver• Largest, chronic infectious disease outbreak of our time• Most don’t know they’re HCV+; There are few symptoms• Easy, inexpensive diagnostic tests can identify HCV • Over time, HCV causes liver damage and cancer• There is a cure for HCV• Liver cancer is on the rise

WHO HAS HCV?BABY BOOMERS

BORN BETWEEN 1945-1965

• Likely living with HCV for decades

•Possibly advanced fibrosis or cirrhosis

•Liver cancer risk - prevention

•Old treatment may not have worked or was REALLY difficult

• Patients are unaware that the current treatment is NOTHING like the old treatments

•Was told one of the following things from Dr:• “You’re not sick enough for

treatment”• “You are using drugs/alcohol and

cannot get treatment”

YOUNG(ER) FOLKS

18-39 YEARS OLD

• Increase transmission in PWUD

• Impact on women of child-bearing age

• Relationship to opioids/heroin and SUDs

•Provider bias for diagnosis

•Prevention

Courtesy of Donald Jensen, MD

YOUR LIVER WON’T TELL YOU, UNTIL…

NATURAL HISTORY OF HCV

Over 5 million in US with HCV

HCV MORTALITY

SYNDEMIC OUTCOMES

SYNDEMIC OUTCOMES

Over 5 million in US with HCV

IS HCV A BIG DEAL?2018 LIST NOTIFIABLE CONDITIONS

Anthrax Arboviral diseases, neuroinvasive and non-

neuroinvasive California serogroup virus diseases Chikungunya virus disease Eastern equine encephalitis virus disease Powassan virus disease St. Louis encephalitis virus disease West Nile virus disease Western equine encephalitis virus disease Babesiosis Botulism Brucellosis Campylobacteriosis Cancer Carbapenemase Producing Carbapenem-

Resistant Enterobacteriaceae (CP-CRE) Carbon monoxide poisoning Chancroid Chlamydia trachomatis infection Cholera Coccidioidomycosis Congenital syphilis Syphilitic stillbirth Cryptosporidiosis Cyclosporiasis Dengue virus infections Severe dengue Diphtheria Ehrlichiosis and anaplasmosis Anaplasma phagocytophilum infection Ehrlichia chaffeensis infection Ehrlichia ewingii infection Undetermined human

ehrlichiosis/anaplasmosis Foodborne Disease Outbreak Giardiasis Gonorrhea

Haemophilus influenzae, invasive disease Hansen's disease Hantavirus infection, non-Hantavirus

pulmonary syndrome Hantavirus pulmonary syndrome Hemolytic uremic syndrome, post-

diarrheal Hepatitis A, acute Hepatitis B, acute Hepatitis B, chronic Hepatitis B, perinatal virus infection Hepatitis C, acute Hepatitis C, chronic Hepatitis C, perinatal infection HIV infection (AIDS has been reclassified as

HIV Stage III) Influenza-associated pediatric mortality Invasive pneumococcal disease Latent TB Infection (TB Infection) Lead, elevated blood levels Legionellosis Leptospirosis Listeriosis Lyme disease Malaria Measles Meningococcal disease Mumps Novel influenza A virus infections Pertussis Pesticide-related illness and injury, acute Plague Poliomyelitis, paralytic Poliovirus infection, nonparalytic Psittacosis Q fever Rabies, animal Rabies, human

Rubella Rubella, congenital syndrome Salmonellosis Severe acute respiratory syndrome-

associated coronavirus disease Shiga toxin-producing Escherichia coli Shigellosis Silicosis Smallpox Spotted fever rickettsiosis Streptococcal toxic shock syndrome Syphilis Tetanus Toxic shock syndrome (other than

streptococcal) Trichinellosis Tuberculosis Tularemia Typhoid fever Vancomycin-intermediate Staphylococcus

aureus and Vancomycin-resistant Staphylococcus aureus

Varicella Varicella deaths Vibriosis Viral hemorrhagic fever Crimean-Congo hemorrhagic fever virus Ebola virus Lassa virus Lujo virus Marburg virus New World arenavirus – Guanarito virus New World arenavirus – Junin virus New World arenavirus – Machupo virus New World arenavirus – Sabia virus Waterborne Disease Outbreak Yellow fever Zika virus disease and Zika virus infection

Over 5 million in US with HCV

RISING MORTALITY: US - 2003–2013

HCV CASCADE

PROGRAM ASSESSMENT TOOL

PROGRAM ASSESSMENT TOOL

PROGRAM ASSESSMENT TOOL

Outreach Detox Tx Rec Home

Ind. Living

Wellness Recovery

+ Rapid Test+ edu. Items

- lab/phleb- Mobile

SSP

+ Rapid and RNA test

+ transport

- Case Mgmt

+referral to onsite care

+ labs+ transport+pharmacy

rltp

- Case Mgmt- FibroScan

+ transport+ rltp with pharmacy

+ 24 hrmonitor,

reminders-access to

cure

+ in house support

-Cancer monitoring

+ Peer support

+prevention+MAT

-re-infection- HCC prev

SELF ASSESSMENT TOOLME, MY JOB, MY OFFICE

Micro Mezzo Macro

My health, my needs, my status, my bias, my stigma

My relationships, my workrole, my knowledge

My next step, my bigger vision, my evolution

ACTION PLAN

Action 1

Action 2

Action3

What actions or changesdo you want to see occur?

Who will carry out these changes?

By when will they take place, and for how long?

What resources (i.e., money, staff) are needed to carry out these changes?

Communication (who should know what?)

PREVALENCETo get a true picture of HCV prevalence, we need dedicated and supported viral

hepatitis surveillance teams funded through local, state and federal government.

Source: Illustration by David H. Spach, MD

TRUE ESTIMATED PREVALENCE

Gen. PopAb+: 1.5% (3.7 mill)RNA: 0.9% (2.1 mill)

Nursing Home Residents

Ab+: 14.7% (23,700)RNA: 10.8% (17,400) Ab+: 1% (13,500)

RNA: 0.5% (6,900)

Ab+: 16.1% (344,100)RNA: 10.7% (227,400)

Add MissedAb+: 400,100RNA: 258,600

Ab+: 1.3% (18,900)RNA: 0.5% (6,900)

THEREFORE…Ab+: 1.7% (4.1 mill)RNA: 1.0% (2.4 mil)

Active MilitaryHomeless People

Incarcerated People

Estimating Prevalence of HCV in US, 2013-1016 – reference on last page

HCV AND CORRECTIONS

• CDC estimates that 16%-41% of inmates in the United States have been exposed to the hepatitis C virus - ANTIBODY

• 12-35% have chronic infection - RNA• HCV can live outside the body in dried blood for up to 3 to 6

weeks, depending on the condition• 30% of Americans with HCV will pass through the corrections

system in any given year

HIV and hepatitis B and C incidence rates in US correctional populations and high risk groups: a systematic review and meta-analysis” BMC public healthvol. 10 777. 21 Dec. 2010, doi:10.1186/1471-2458-10-777

Diagnosis, treatment and cure of HCV+ inmates is a vital public health strategy and a key to achieving elimination.

IN ONE DROP OF BLOOD WITH HBV, HCV AND HIV…

Beltrami, E. Et al. Clin Microbiol Rev. 2000 Jul;13(3):385-407.

WHAT IS A SYNDEMIC?SYN (SYNERGY) + DEMIC (SUFFIX OF EPIDEMIC)

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)30003-X/fulltext

• CDC identifies a syndemic is

a synergistically interacting

epidemic.

• MedicineNet.com defines a

syndemic as a set of linked

health problems involving 2

or more afflictions,

interacting synergistically,

and contributing to excess

burden of disease in a

population.

EXAMPLE OF SYNDEMICS: HAV

No vaccineUnsanitary conditions

Homeless population

Hepatitis A Outbreak

“The cost of a single Hepatitis A outbreak (250 sick people) can be upwards of $1.9 million dollars –including lost revenue, lawsuits,

legal fees, fines and medical costs.”https://www.bioiq.com/curb-costly-outbreaks-hepatitis-a-

vaccination/

EXAMPLE OF SYNDEMICS: KENTUCKY

Poverty; Stigma; Health Care Access;

Transportation

Opioid Use Disorders; Overdose;

OverRx The rise in HCV among women of childbearing age:

National Statistics: 22%Kentucky Statistics: 213%

The rise in proportion of babies born to women with HCV:

National Statistics: 68%Kentucky Statistics: 124%

EXAMPLE OF SYNDEMICS: AUSTIN, IN

War on Drugs; Criminalization

of Drug Use; Stigma; No

SSP; poverty

Opana -Opioid Use Disorders; Overdose; Scott County, IN

• 11 confirmed HIV cases sparked investigation

• Identified 215 HIV+ w/in 4200 person county

• 84% co-infected HIV/HCV• Indiana spent $16M+ through

August 2015 to stop the outbreak (in 1 county!)

EXAMPLE OF SYNDEMICS: CORRECTIONS

CURRENT SNAPSHOT

• Medicaid Restriction Removal• National Viral Hepatitis Action Plan• ECHO Chicago HCV Training

• University of Chicago• HCV Screening, Testing & LTC Programs• Current Rates of Incarceration

https://www.chicagotribune.com/business/ct-illinois-relaxes-restrictions-hepatitis-c-drugs-1115-story.html

CURRENT SNAPSHOT• Hepatitis C Surveillance Report– Chicago, 2016 - REPORTING! REPORTING! REPORTING!

• less than 2% of all reported HCV cases include documentation of symptoms, elevated liver function tests, or a prior negative test to confirm recent infection

THINGS TO KEEP IN MIND

INTEGRATION COMPONENTS

1. Prevention & Education

2. Screening & Testing

3. Vaccination

4. Staging

5. Cure

6. Recovery & Support

1. PREVENTION & EDUCATION

1. Knowledge & skill building1. Consistent messages are crucial!

2. Infection, re-infection and transmission1. SSPs, MAT, Adolescents, Maternal Care, Liver Cancer

3. Similarities & differences with HIV & HCV

4. Training and Education1. Caring Ambassadors Program HCV training workshop

2. ECHO

3. Other online resources

2. SCREENING & TESTING1. Technology – standard of care, staff training & cost of test

1. Rapid vs. Laboratory2. Reflex testing options

2. Documentation:1. CLIA waiver2. Physician Standing Order (PSO) – location dependent3. Patient Consent w/ reporting info

3. Administrative code on reporting

4. Integrating w/ parallel HIV testing

5. Confirmatory testing is TESTING!

6. Referral options for additional testing, treatment and care

7. PAP resources for diagnostics

2. SCREENING & TESTING

Antibody testing – blood test to determine exposure

PCR/RNA testing* – confirms the presence of active infection/virus

Genotype testing – important for determining treatment course

Viral load testing* – determines how much virus in blood and important during treatment response

TITLE 77: PUBLIC HEALTH CHAPTER I: DEPARTMENT OF PUBLIC HEALTH

SUBCHAPTER k: COMMUNICABLE DISEASE CONTROL AND IMMUNIZATIONS

PART 690 CONTROL OF COMMUNICABLE DISEASES CODE

SECTION 690.452 HEPATITIS C, ACUTE INFECTION AND NON-ACUTE CONFIRMED INFECTION (REPORTABLE BY

MAIL, TELEPHONE, FACSIMILE OR ELECTRONICALLY, WITHIN 7 DAYS)

Section 690.452 Hepatitis C, Acute Infection and Non-Acute Confirmed Infection

(Reportable by mail, telephone, facsimile or electronically, within 7 days)

a) Control of Case. Standard Precautions shall be followed.

b) Control of Contacts. No restrictions.

c) Laboratory Reporting. Laboratories shall report to the local health authority patients who are anti-HCV

positive by immunoassay (e.g., enzyme immunoassay, chemiluminescence immunoassay) with a signal-to-

cutoff ratio (S/C) or other parameter predictive of a true positive as determined for the particular assay (S/C should

be included with all test results that are reported) or who test positive for hepatitis C by recombinant

immunoblot assay, polymerase chain reaction (PCR) or any other supplemental or confirmatory test that may

be used. Results of the alanine aminotranferase testing that are closest in time to the date of the positive hepatitis

C result and within 3 months of the positive test for hepatitis C should be reported concurrently with the positive

immunoassay, PCR, immunoblot or other confirmatory test results. Viral genotype results (when performed)

should also be reported. Laboratories not performing confirmatory testing or tests to identify highly positive

specimens (e.g., S/C) shall report selected hepatitis C results as requested by the Department.

(Source: Amended at 32 Ill. Reg. 3777, effective March 3, 2008)

http://www.ilga.gov/commission/jcar/admincode/077/077006900C04520R.html

3. VACCINATION

1. Vaccination is an Important Prevention Measure!!

2. How to obtain vaccine?

3. Cost & Reimbursement

4. PSO for vaccination1. PSO for Medical Management of Vaccine Reactions in Adult Patients

5. HAV, HBV or Twinrix

6. Inoculation Schedule: standard vs. accelerated

7. Storage & Temperature Log

8. Staff and follow-up

IAC – www.immunize.org

4. STAGINGStaging = process of identifying the extent of liver damage

1. Identification of Treatment Options & Provider1. PA checklist

2. Sobriety, relapse prevention and safety planning

3. Support & Social Determinants of Health

4. Costs1. Patient Assistance Programs

5. Retention & Treatment Adherence Plan

6. Medication education & Health Literacy

5. CURE

1. Medication adherence

2. Lab monitoring

3. Refill reminder process

4. Education

5. Follow up

6. Surveillance

6. WELLNESS & SUPPORT

1. Group Support

2. Prevention1. New infection2. HCC3. NAFLD – Fatty Liver Disease

3. Medical Doctor vs. Specialist (Hepatologist) and ongoing surveillance

4. Behavioral health/Addiction treatment providers

5. MAT

6. Pharmacist

7. Housing

8. Stigma Elimination

CLINICAL & PROGRAM CONSIDERATIONS

WHAT CAN YOU DO NOW?

• Test & Empower• Yourself & loved ones

• People who are incarcerated

• Those who serve them

• Connect• Prior to release, start process of connecting to care and healthcare

discussion

• Educate & Resources• Caring Ambassadors Program

• National Hepatitis Corrections Network

• Centers for Disease Control

• University of New Mexico, Project ECHO Peer Education Project

• University of Washington – Hepatitis C Online at UW

• Illinois Hepatitis Elimination Task Force

ASSESSMENT & DISCUSSION

RESOURCESCaring Ambassadors Program http://www.hepcchallenge.org/

National Viral Hepatitis Roundtable: http://nvhr.org/

HCV Advocate: www.hcvadvocate.org

The Hepatitis C Mentor & Support Group, Inc. (HCMSG): http://www.hepatitiscmsg.org

Immunization Action Coalition: http://www.immunize.org/

CDC https://www.cdc.gov/hepatitis/index.htm

Project ECHO https://echo.unm.edu/

National Viral Hepatitis Action Plan https://www.hhs.gov/hepatitis/viral-hepatitis-action-plan/index.html

QUESTIONS

Thank you!

Any questions?

Jill Wolf, LCSW

Hepatitis C Program Director

Jill@CaringAmbassadors.org

REFERENCES

HIV and hepatitis B and C incidence rates in US correctional populations and high risk groups: a systematic review and meta-analysis” BMC public healthvol. 10 777. 21 Dec. 2010, doi:10.1186/1471-2458-10-777

Estimating Prevalence of Hepatitis C Virus Infection in the United States, 2013‐2016. Megan G. Hofmeister; Elizabeth M. Rosenthal; Laurie K. Barker; Eli S. Rosenberg; Meredith A. Barranco; Eric W. Hall; Brian R. Edlin; Jonathan Mermin; John W. Ward; A. Blythe Ryerson First published: 06 November 2018 https://doi.org/10.1002/hep.30297

https://chicago.gov/content/dam/city/depts/cdph/CDPH/Healthy%20Chicago/2016ChicagoHCVReport_FINAL_07272018b.pdf

https://www.hhs.gov/sites/default/files/National%20Viral%20Hepatitis%20Action%20Plan%202017-2020.pdf