Rachel Stallings MPH March 4 2020 Hepatitis Hepatitis inflammation of the liver Can be selflimiting or progress to fibrosis scarring cirrhosis or liver cancer Causes Most commonly caused by a virus there are 5 A B C D amp E ID: 917481
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Slide1
Hepatitis Testing and Treatment Update
Rachel Stallings, MPH
March 4, 2020
Slide2Hepatitis
Hepatitis = inflammation of the liver
Can be self-limiting or progress to fibrosis (scarring), cirrhosis, or liver cancer.
Causes:Most commonly caused by a virus, there are 5: A, B, C, D & EA & E = fecal oral route B, C, D = blood and body fluids D can only occur as a co-infection w/ BOther Causes:Toxic substances (alcohol, certain drugs)Autoimmune diseases
Source:
https://www.who.int/features/qa/76/en/
Slide3Acute and Chronic
Acute
Fever, fatigue, nausea, abdominal pain, jaundice, etc.
Supportive Care
Treatable
Slide4Symptoms of Acute Hepatitis A, B and C
Loss of appetite
Fever
FatigueNauseaVomitingAbdominal painGray-colored bowel movementsJoint painJaundice – most common with HAV
*Most people do not experience any symptoms
Slide5Hepatitis B and C in Virginia
Slide6Incidence of Acute HBV and HCV by Year
VEDSS data as of 2/14/20
Slide7Incidence of Chronic HBV and HCV by Year
Slide8Hepatitis B in Virginia – Number of Reported Cases
VEDSS data as of 2/14/20
Slide9Time Progression of
HBV
Rates by County per 100,000 persons
(including incarcerated individuals)
Slide10Hepatitis C in Virginia – Number of Reported Cases
VEDSS data as of 2/14/20
Slide11Time Progression of HCV Rates by County per 100,000 persons
(including
incarcerated individuals
)
Slide12Number of HCV Cases by Age and
Sex
Slide13Hepatitis B and C Testing
Slide14USPSTF HCV Screening Recommendation
Source: https
://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/hepatitis-c-screening1
Slide15Hepatitis B Testing
2018
HBsAg
Tests Total HBsAg Tests: 5,820Positive: 43
Positivity:
~1%
2019
HBsAg
Tests
Total
HBsAg
Tests: 8,277
Positive: 52
Positivity: ~ 1%
Slide16Hepatitis C Testing
2018
Conventional (clinical sites)
Total HCV Ab tests: 6,770Reactive results: 618Antibody Positivity: 9%
RNA Confirmed: 435 (66%)
Rapid (non-clinical sites)
Total HCV Ab
tests: 3,442
Reactive Results:
442
Antibody Positivity:
13%
2019
Conventional (clinical sites)
Total HCV Ab tests: 9,072
Reactive results: 670
Antibody Positivity: 7%
RNA Confirmed: 447 (64%)Rapid (non-clinical sites)Total HCV Ab tests: 4,675
Reactive Results: 358
Antibody Positivity: 8%
Slide17Treatment OF viral hepatitis
Slide18Treatment
Hepatitis A
Supportive care (acute disease only)
Hepatitis BThere is treatment for HBV, but not a cureImmune Modulator drugs - (interferon-type drugs) boost the immune systemAntiviral drugs - reduce the viral load hepatitis B by slowing viral replicationNot everyone with hepatitis B will be placed on a treatment courseOn-going human clinical trials for new therapies Hepatitis COver 90% of HCV infected persons can be cured of HCV infection, regardless of genotype
8-12 weeks of oral therapy depending on severity
Therapies achieve sustained
virologic
response (SVR); SVR is indicative of a cure
12 weeks post-treatment lab result showing no virus in the blood = SVR = Cure
Slide19Hepatitis C Treatment – Updates
Simplified treatment
for adults with chronic hepatitis C (any genotype) who do not have cirrhosis and have not previously received hepatitis C treatment.
https://www.hcvguidelines.org/treatment-naive/simplified-treatmentTreatment of acute HCVNew recommendation for initiating treatment without waiting periodhttps://www.hcvguidelines.org/unique-populations/acute-infection
Treatment of HCV in children
New regimens for ages 3-11
https://www.hcvguidelines.org/unique-populations/children
Special populations: People Who Inject Drugs
Active or recent drug use or a concern for reinfection is not a contraindication to HCV treatment
https://
www.hcvguidelines.org/unique-populations/pwid
Other updates:
What's New, Updates and Changes to the Guidance
Slide20AIDS Drug Assistance Program (ADAP)
Recommendations:
https://
www.hcvguidelines.org/unique-populations/hiv-hcvHIV clients who use Virginia Medication Assistance Program (VA MAP) and who are co-infected with HCV can procure Hepatitis treatment through VA MAP as wellAs of April 201894 clients accessed85 clients complete treatment
3 clients in treatment
Slide21HCV Treatment: Insurance Restrictions
Medicaid – Removed barriers for treatment access. Previously required that patients meet a sobriety requirement, prescriber must be a specialist (or in consult with one), and patient must meet a certain fibrosis score.
Prior Authorization no longer requires genotype test for preferred drugs –
Mavyret and Epclusa DMAS HCV Prior AuthorizationPAPs:
Mavyret
requires a
fibroscan
Harvoni
requires Medicaid application with denial
Private insurance – Requires genotype test
Slide22HCV Treatment Resources
Recommendations for Testing, Managing, and Treating Hepatitis C
AASLD and IDSA recommendations
https://www.hcvguidelines.org/contentsHEPline: The Univeristy of California, San Francisco’s, Clinician Consultation Center provides hepatitis C management consultation to health center providers. This is a free, real-time clinician-to-clinician telephone consultation.
Warmline
toll-free: 1-844-437-4636 (Monday – Friday 9am -8pm EST)
Website:
http
://nccc.ucsf.edu/clinician-consultation/hepatitis-c-management
/
Hepatitis C Online
Free online educational website from the University of Washington. Contains comprehensive resources that address diagnosis, monitoring, and management of HCV infection.
https://www.hepatitisc.uw.edu/
Slide23VDH – UVA Treatment Pilot
Overview:
Goal 1: to increase primary care capacity for HCV treatment
Goal 2: to treat and cure 70 patients living with HCVGoal 3: Learn and troubleshoot barriers to care (lab costs, liver scoring, medication procurement, referral to specialists)Methods:Provider training – one day learning intensive with CMEs. Clinician training and support staff training. On-going monthly case study and consultation calls for training attendeesUVA specialist (infectious disease) provides consultation to sites treating independently
UVA offers a telehealth option for HCV treatment
Slide24VDH – UVA Treatment Pilot Outcomes
Data as of January 22, 2020
Referrals: 212
Fibroscans: 191Appointments Attended: 181Patients w/ Rx: 172Patients Completed Tx
: 116
awaiting SVR: 51 / confirmed SVR: 65
Provider Training:
3 trainings complete (June, September, December)
4
th
training scheduled for March 13, 2020
Post Training Outcomes:
11 providers treating independently
13 providers treating via UVA telehealth
Slide25Questions? Comments?
Rachel Stallings
Viral Hepatitis Epidemiologist
Rachel.stallings@vdh.Virginia.govNicole Barron Viral Hepatitis Testing CoordinatorNicole.barron@vdh.Virginia.govKaity
Hauter
Viral Hepatitis Program Coordinator
Kaitlyn.hauter@vdh.Virginia.gov