Hepa%%s C Epidemiology in West Virginia. Judith Feinberg, MD Project ECHO Nov. 3, 2016

Transcription

1 Hepa%%s C Epidemiology in West Virginia Judith Feinberg, MD Project ECHO Nov. 3, 2016

2 Acute HCV in Appalachian Youth < % increase in cases (n=1377) from in WV, VA, TN & KY Similar to data from upstate NY, MA, WI and OH in same period Tied to injecwon of opioids among whites in rural & small urban areas IDU was risk factor in 73% Zibbell JE et al. MMWR Weekly May 8, 2015

3 Why is case rate for acute HCV so low? Subclinical infecwon is common.

4 Why do case rates for acute and chronic HBV track so closely? Most people get sick.

5 Nicholas Lincoln Boone Fayette Greenbrier mm o ers Raleigh ng Mi Logan Wyoming Su Wayne Kanawha Po ca ho n Cabell ta s 2012 McDowell Mercer Monroe

6 2013

7 2014

8 2015

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10 Southeast Indiana: Recent Scoc County HIV Outbreak (190 cases)* OH Cincinna& AusWn KY * >90% are co-infected with hepawws C

11 Demographic Characteris%cs of ScoB County It has the worst health status of Indiana s 92 counwes Limited access to healthcare 9% unemployment 19% poverty rate 21% without a high school diploma Brooks JT. The evolving epidemiology of HIV infecwon in persons who inject drugs: Indiana CROI; Boston, MA; February 22-25, 2016, abstract 132.

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13 West Virginia Coun%es at Risk for HIV and/or Hepa%%s C Outbreaks 28 of 220 high-risk counwes are in WV (13% of US total) WV had 2 nd highest number of risk counwes in the US (KY is #1 with 54, 25% of total) >50% are in Appalachia

14 Impact of HIV Co-infec%on with Chronic Viral Hepa%%s Bilateral synergy between HIV and chronic viral hepawws, esp. HCV HIV augments the clinical progression of HCV HCV augments the clinical progression of HIV For example, if progression to cirrhosis/esld takes ~25-30 years in adults with HCV mono-infecwon, this typically occurs in ~10-15 years (or faster) in HCV/HIV co-infecwon Urgency to prevent/treat/cure chronic viral hepawws in HIV co-infected persons

15 Routes of Transmission of HIV and Hepa%%s B & C HIV Hepa&&s C Hepa&&s B blood sex motherto-child

16 Why is this important? AcquisiWon of HIV, hepawws B & hepawws C in women of child-bearing age Primary routes of infecwon InjecWon drug use (primary) Unprotected sex (secondary) Mother-to-child transmission (MTCT) of these viruses occurs at varying rates but may have serious consequences for the neonate

17 Why is this important now? Ongoing epidemic of injecwon opioid use both prescripwon drugs and street drugs (heroin, somewmes laced with fentanyl, fentanyl analogs, carfentanil, gabapenwn, etc) Although iniwally concentrated among young men, now close to half of the opioid-dependent individuals in WV are women of child-bearing age

18 Mother-to-Child Transmission of HCV Rate of verwcal transmission variable, but is > 5% in moms with HCV monoinfecwon and > 10% in moms with HIV co-infecwon Pathogenesis during pregnancy poorly understood HCV viral load increases and peaks in 3 rd trimester Currently no effecwve prevenwon methods Possible surveillance approach: tox screen all women presenwng for L&D; hepawws C screen in tox-posiwve moms to ensure adequate pediatric f/u for babies

19 Most Recent Es%mates of HCV MTCT Risk Review and meta-analysis of observawonal studies published since the last review in 2001 Goal: define proporwon of infants diagnosed with HCV at 18 months born to HCV AB+ and RNA+ women EsWmates of HCV verwcal transmission: HIV- moms HIV+ moms range of MTCT risk 1.1%-10.7% 4.2%-28.5% pooled risk (all studies) 5.8% 10.8% Benova L et al. VerWcal Transmission of HepaWWs C Virus: SystemaWc Review and Meta-analysis. CID 2014; 59:

20 Mother-to-Child Transmission of HCV VerWcal transmission is leading cause of pediatric HCV, up to 4,000 new cases each year in the U.S % of HCV-infected pregnant women do not iniwally report major risk factors for HCV Rate higher in mothers with: High viral load at delivery HIV co-infecwon PROM Use of internal fetal monitoring devices No means of prevenwon (except birth control)

21 HCV in women of childbearing age & in children <2 y/o, KY * *KY had highest rate of acute HCV in U.S.,

22 Increasing propor%on of infants born to HCVinfected moms, KY

23 Long-term Outcome of HCV MTCT Most children asymptomawc with mild liver abnormaliwes Both transient and chronic infecwons occur Studies* following pawents for 10 to 20 years auer perinatal acquisiwon show: 5%-12% have significant fibrosis 5% have cirrhosis *Guido M et al. Fibrosis in chronic hepawws C acquired in infancy: is it only a macer of Wme? Am J Gastroenterol 2003; 98: ; Mohan P et al. Clinical spectrum and histopathologic features of chronic hepawws C infecwon in children. J Pediatr 2007; 150: , 174.e1