Hepatitis C Project

Overview

Hepatitis C Virus (HCV) is a common infection, with an estimated 3.5 million persons chronically infected in the United States. According to the Centers for Disease Control and Prevention, American Indian and Alaska Native people have the highest mortality rate from hepatitis C of any race or ethnicity. But Hepatitis C can be cured and our Portland Area IHS, Tribal and Urban Indian primary care clinics have the capacity to provide this cure. Some of these clinics have already initiated HCV screening and treatment resulting in patients cured and earning greatly deserved gratitude from the communities they serve.

HCV has historically been difficult to treat, with highly toxic drug regimens and low cure rates.  In recent years, however, medical options have vastly improved: current treatments have few side effects, are taken by mouth, and have cure rates of over 90%.  Curing a patient of HCV greatly reduces their risk of developing liver cancer and liver failure.  Early detection of HCV infection through routine and targeted screening is critical to the success of treating HCV with these new drug regimens.

Goals

It is estimated that as many as 120,000 AI/ANs are currently infected with HCV. Sadly, the vast majority of these people have not been treated. By treating at the primary care level, we can begin to eradicate this disease.

Our aim is to provide resources and expertise to make successful treatment and cure of HCV infection a reality in Northwest IHS, Tribal and Urban Indian primary care clinics. We hope you will join us in this important endeavor.

Stay Connected

Text Flyer

In order to better understand HCV among Northwest Tribes, the Northwest Portland Area Indian Health Board performed Electronic Health Record (EHR) audits in 2016 to determine caseload estimates and raise awareness of HCV disease in the Portland Area. The project identified persons in EHRs with a probable HCV diagnosis, demographic characteristics and clinical laboratory markers to determine stage of liver disease. 635 unique patients were found with an HCV diagnosis, and 382 (60%) were born between 1945 and 1965.  This represents only a small fraction of the total number of baby boomers in the Portland area that have been screened 2444/6812 (35.8%), despite the CDC recommendation that all people born between 1945 and 1965 get tested for hepatitis C.

Each month, the Northwest Portland Area Indian Health Board offers a TeleECHO clinic with Dr. Mera focusing on the management and treatment of patients with HCV. The 1 hour long clinic includes an opportunity to present cases, receive recommendations from a specialist, engage in a didactic session and become part of a learning community. Together, we will manage patient cases so that every patient gets the care they need.

When: The fourth Wednesday of every month at 12pm PST

How: Sign up below to join our email listserv and or text HCV to 97779. We’ll be sure to send you the connect information each month.

Stay Connected

Present your case to our Hepatitis C specialist for best practice treatment recommendations. If you would like to present, please complete the Case Presentation form and send to David Stephens via email (dstephens@npaihb.org) or fax (503.228.4801) Download the case presentation form>>

  • Introduction

    An estimated 3 million to 4 million persons in the United States are chronically infected with HCV, and approximately half are unaware of their status. These individuals may ultimately progress to advanced liver disease and/or hepatocellular cancer (HCC). However, those outcomes can be prevented by treatment, which is rapidly improving and offers the potential of a cure to more patients than has been previously possible.

    HCV causes more deaths than all reportable infectious diseases combined, including HIV/AIDS, and its impact on public health in Indian Country is considerable.  This letter will outline the HCV burden, progression of disease, and medical options to reduce HCV related mortality.

  • Epidemiology and Transmission

    Because HCV is a bloodborne infection, risks for HCV transmission are primarily associated with exposures to contaminated blood or blood products. The highest prevalence of antibody to HCV (anti-HCV) was documented among persons with substantial or repeated direct percutaneous exposures, such as persons who inject drugs (PWID), those who received blood from infected donors, and persons with hemophilia (60%–90%); moderate rates were found among those with repeated direct or unapparent percutaneous exposures involving smaller amounts of blood, such as hemodialysis patients (10%–30%). Persons with unapparent percutaneous or mucosal exposures, including those with high-risk sexual behaviors, sexual and household contacts of persons with chronic HCV infection (1%–10%), and persons with sporadic percutaneous exposures (e.g., health-care workers [1%–2%]), had lower rates.

    The Birth Cohort 1945-1965 are estimated to have 75% of the HCV disease burden, with differing interpretations of exposures via injecting drug use and medical exposures. Factors for the subsequent decline in HCV infections may include safer injecting practice among PWID, infection saturation among PWID, stronger universal precautions in medical settings, and blood donor screening.

  • NW AI/AN Epidemiology

    Recently, both Oregon and Washington have compiled epidemiologic data on the impact of hepatitis C in their states. The Oregon report entitled “Viral Hepatitis in Oregon” (available at: https://public.health.oregon.gov/DiseasesConditions/HIVSTDViralHepatitis/AdultViralHepatitis/Documents/Viral_Hepatitis_Epi_Profile.pdf) was released in May, 2015; the Washington report, entitled “Viral Hepatitis C in Washington State” (available at: http://www.doh.wa.gov/Portals/1/Documents/Pubs/420-159-HCVEpiProfile.pdf), was released in June, 2016.  The data in these two reports has not been corrected for misclassification of AI/AN race, so the disparities described are likely even greater than the current data demonstrates.

    • Oregon:
      • Morbidity: Approximately 25 new cases of acute HCV infection are reported annually in Oregon and has been stable during the period 2009—2013. The actual number of cases that go unreported is much higher, as high as 332 new cases each year. AI/AN have the highest rate of acute HCV infection in OR compared to other races/ethnicities (2.1 cases/100,000 persons compared to 0.6/100,000 for non-Hispanic Whites. Chronic HCV cases number approximately 5,087 annually. The highest rate is again found in AI/AN (127.7/100,000), more than twice the rate of non-Hispanic Whites (57.5/100,000).
      • HCV-related hospitalizations numbered 3,917 from 2008—2012 with an average cost of $26,961 per admission. Admissions for treatment of liver cancer, chiefly, hepatocellular carcinoma (HCC) were the most expensive component of these costs averaging $52,345 per admission. HCC was the most common malignant outcome associated with HCV infection with 763 cases report from 1996—2012. In 2012, 47% of all HCC cases were attributed to chronic HCV infection. Again, AI/AN have the highest rates of HCC (4.1/100,000) compared to non-Hispanic Whites (3.1/100,000).
      • Mortality: HCV-related mortality in Oregon was higher in 2011 than in the US as a whole 8.7 vs. 4.8 deaths per 100,000 persons. From 2009—2013, Oregon HCV-related deaths mirrored national figures in that most were male (71%) and in the baby-boomer age range, 45—64 (80%). AI/AN in Oregon have the highest rate of HCV-related mortality (17.4 deaths/100,000 persons, almost twice the rate for non-Hispanic Whites (8.9/100,000).
    • Washington:
      • Morbidity: The number of acute HCV cases reported in Washington State has risen steadily since 2010. In the latest reporting year (2014), 83 cases of acute HCV were reported for an annual incidence of 1.2/100,000 persons. This represents the tip of the ice-berg – CDC estimates that only 7% of cases are reported so the true number of new Hepatitis C infections could be as high as 1,154. During the period from 2010—2014, AI/AN were over-represented accounting for 6.1% of acute HCV infections, while only making up 1% of the State population in 2014.
      • Chronic HCV infections have remained fairly stable over time in Washington State with 5,967 cases in 2014 (85.6/100,000). The majority of chronic HCV cases have unknown race/ethnicity information (82.8%). AI/AN account for 1.3% of chronic HCV cases where race/ethnicity is identified.
      • During the period 2010—2014, hospitalization rates for HCV infection have nearly doubled from approximately 87/100,000 in 2010 to 160/100,000 in 2014 whereas hospitalizations for hepatitis B and HIV infections have remained stable at around 20/100,000 and 30/100,000, respectively. Nearly all hospitalizations for HCV–related conditions were for emergency or urgent conditions and just under one-third of individuals hospitalized for HCV-related conditions experienced readmission. AI/ANs account for 4% of HCV-related hospitalizations. The age-adjusted rate of hospitalization for AI/ANs was nearly three times the rate for the non-Hispanic White population of approximately 6/100,000. From 2010—2013, diagnosis of liver and intra-hepatic bile duct cancer was also three times higher for AI/ANs (22.34/100,000) than for non-Hispanic Whites (7.27/100,000). AI/ANs account for approximately 3% of all liver and intra-hepatic bile duct cancers in Washington and 2% liver transplants.
      • Mortality: The number of HCV-related deaths in Washington increased for the period from 2000—2014 from 262 (4.4/100,000) to 645 (7.2/100,000). During this period, the age-adjusted mortality rate for AI/ANs has grown faster than for any other race or ethnicity. For the period from 2010—2014, the AI/AN Mortality rate of approximately 17/100,000 persons was approximately three times that of non-Hispanic Whites. AI/AN deaths accounted for about 4% of HCV-related deaths in Washington.
      • Screening: Testing at State-funded screening sites showed an overall positivity of 28.8% for 4,876 screening tests performed, ranging from 0% to 65.7% across a variety of testing locations.

Lummi Tribal Health Staff

“Treating hepatitis c is no more complicated than treating other chronic diseases like diabetes. While it may seem like a daunting task at first, with proper training and cooperation with specialists, we are proving that hepatitis c is treatable in our communities, by our own providers.”

-Justin Iwasaki, MD, MPH Executive Medical Director, Lummi Nation

It is estimated that as many as 120,000 AI/ANs are currently infected with HCV. Sadly, the vast majority of these people have not been treated. By treating at the primary care level, we can begin to eradicate this disease.

Our aim is to provide resources and expertise to make successful treatment and cure of HCV infection a reality in Northwest IHS, Tribal and Urban Indian primary care clinics. We hope you find this change packet to be a useful tool in this important endeavor: Change Packet

The Northwest Portland Area Indian Health Board hosted a free clinical training for I/T/U facilities to provide a range of HCV services at the primary care level with Dr. Jorge Mera, Director of Infectious Diseases for Cherokee Nation Health Service. Please view and download all of the training materials here:

New drug regimens have made early detection and treatment of HCV critical, although the main barriers to treatment have been cost and complex prior-authorization processes. The new medications have been among the most expensive in history, although private and public insurance companies are beginning to cover the two to three month oral regimen and help cure this chronic disease. Fortunately in many states, including Washington, Medicaid will approve payment for nearly every patient with chronic HCV; this includes patients who are actively injecting drugs and/or using alcohol. Other private insurance companies will also cover the new medications, and patient assistance programs now provide free medication for eligible patients.

On January 6, the Indian Health Service issued a Dear Tribal Leader Letter to announce that the IHS recently signed an Interagency Agreement with the U.S. Department of Veterans Affairs (VA) authorizing the IHS to use the VA Veterans Health Administration’s Consolidated Mail Outpatient Pharmacy (CMOP). With this development, Tribes and Tribal organizations with Indian Self-Determination and Education Assistance Act (ISDEAA) agreements will now be able to access the CMOP through the National Supply Service Center (NSSC). The cost of medications will be the same as what the VA is able to purchase the medications for ( e.g. IHS, Tribal and VA Price for Harvoni (28 tablets) $5,750.00).

For additional drug costs and any questions related to access or eligibility for CMOP at your IHS or Tribal pharmacy, please directly contact CAPT Todd Warren, IHS National CMOP Coordinator, by telephone at (605) 390-2371 or by e-mail at todd.warren@ihs.gov. You can also:

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