Hepatitis C in Massachusetts Michael Gaucher and Shauna Onofrey MA Department of Public Health Bureau of Infectious Disease & Laboratory Sciences

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1 Massachusetts Department of Public Health Bureau of Infectious Disease and Laboratory Sciences Hepatitis C in Massachusetts Michael Gaucher and Shauna Onofrey MA Department of Public Health Bureau of Infectious Disease & Laboratory Sciences

2 What is Hepatitis? General term originating from the Greek: Hepa which means liver itis which means inflammation Can be caused by: Alcohol Drugs/medications Toxins/chemicals Autoimmune diseases Bacteria Viral infections (hepatitis A, B, C, D, and E)

3 Fatigue Possible Symptoms of Liver Loss of appetite Nausea Vomiting Abdominal pain Jaundice Damage Over time, damage to the liver can lead to scarring of the liver tissue (cirrhosis) End stage liver disease can cause death

4 Viral Hepatitis Alphabet Soup Hepatitis A Virus (HAV, fecal-oral transmission, vaccine available) Hepatitis B Virus (HBV, blood-borne, vaccine available) Hepatitis C Virus (HCV, blood-borne) Hepatitis D Virus (blood-borne, only causes problems for people infected with HBV) Hepatitis E Virus (fecal-oral, occurs rarely in U.S.) 4

5 Acute vs Chronic Viral Hepatitis Infection Acute infection: short term, initial stage of infection Chronic infection: the infection doesn t go away and can lead to serious liver damage over time

6 Quick information: Hepatitis A Causes acute (short term) infection only. IgM+ indicates infection: Only test if patient has symptoms Is transmitted through fecal-oral route Concern is typically around food handlers We are seeing an increase in MSM Vaccine preventable (treatment for close contacts is also vaccination). Infectious 2 weeks before symptoms start to 1 week after Incubation period: days Immediately Reportable to MDPH and will prompt response from the Epidemiology Program ( )

7 A Closer Look at Hepatitis B and C Both blood-borne HBV more efficient than HCV for sexual and mother-to-child transmission Both can cause chronic disease, leading to cirrhosis and liver cancer Hepatitis B is vaccine preventable Hepatitis C can be cured

8 Quick Information: Hepatitis B Vaccine preventable Can be given in a combination vaccine with Hep A A new 2 dose vaccine is now available! Can be treated (not curative) More likely to develop chronic infection if initially exposed at a younger age Most chronic cases in the US are among people who immigrated from countries where hepatitis B is very common Emerging issue for PWID: Cluster in Bristol County

9 Hepatitis C

10 Key Issues with Hepatitis C Infection Yes: Hepatitis C infection can be cured No vaccine Most people who are exposed go on to have chronic infection Can lead to cirrhosis, liver cancer, death Deaths due to hepatitis C infection are increasing Two different epidemics in US: Baby boomers (born between ) Young people who inject drugs

11 HCV Transmission: It s all about the blood

12 HCV Transmission Currently, most people infected through injection drug use (sharing drug injection equipment) Sharing of syringes, cookers, cottons, rinse water, etc. from injection drug use is the greatest risk for HCV transmission Prior to 1992, many people also exposed through blood transfusions/clotting factors/organ transplants 12

13 HCV Transmission and Injection Drug Use Unlike HIV, cleaning works with bleach is not nearly as effective with HCV The hepatitis C virus is still present and can still infect someone: Up to 63 days in a syringe barrel Up to 21 days in H2O in a plastic container Up to 6 weeks on inanimate surfaces

14 Other Possible Transmission Routes Sexual transmission - inefficient but does occur Vertical transmission 4-7% of births to infected mothers (20% in HIV/HCV coinfected) Sharing personal/household items with blood Intranasal drug use Tattoo/body piercing: nonsterile practices 14

15 Hepatitis C Screening Who should be screened for Hepatitis C? Anyone who have ever injected illegal drugs or shared drug equipment Baby boomers born between Anyone who is living with HIV Persons with other risk factors, such as chronic hemodialysis, persistently abnormal ALT levels, history of blood transfusions before 1992, a sexual partner with HCV, or a recent needle stick.

16 Hepatitis C Tests and Labs Hepatitis C Antibody test Indicates if the person has ever been exposed to HCV Does not indicate if the person currently has HCV Hepatitis C RNA (NAT or NAAT) test Indicates if the person currently has HCV RNA/Viral load test measures the amount of virus in the blood stream Hepatitis C Genotype test Used to determine appropriate treatment Helps DPH understand who has been linked to care

17 Hepatitis C Treatment New treatments are highly effective! Most treatment courses are 8-12 weeks (depending on other health factors and previous treatment) Treatments are effective for people who are coinfected with HIV/HBV/STDs (however treatment can re-activate HBV) Individuals with cirrhosis can be treated

18 Hepatitis C Treatment cont Restrictions (sobriety, fibrosis score, etc) have largely been lifted by local insurance providers including MassHealth Still issues with some providers treating individuals who are actively using or who don t have a lot of clean time, sometimes due to provider concerns about re-infection Everyone deserves to be treated!

19 MDPH Funded Services Newly procured integrated HIV/HCV/STI/TB service system Integrated screening Linkage to care and treatment with support for treatment completion Linkage to care for individuals coming out of correctional facilities

20 Hepatitis Data and Response MDPH Receives, processes, and analyzes lab results. Collects additional data through provider case reports Describes epidemic characteristics including: Demographics Geography Reported risk factors See HCV annual report:

21 Rate of Reported Confirmed and Probable HCV Cases per 100,000 Population by Official Massachusetts City/Town*: 2015

22 IDU Syndrome

23 Reported Risk Factors for HCV Infection in MA, Confirmed and Probable HCV Cases , N=76,958 Confirmed Acute HCV Cases , N=1,953 Data source: Massachusetts Department of Public Health, Bureau of Infectious Disease and Laboratory Sciences. Hepatitis C Virus Infection Surveillance Report, Published January Data as of November 16, 2016 and subject to change.

24 HCV Care Cascade Reported Cases (12%) RNA- (49%) RNA+ *(78%) *(39%) HCV EIA+ HCV RNA HCV retained in care HCV intent to treat Sustained Virologic Response Proportion of Cases at Successive Stages of Care *(2%) * % of RNA+ cases

25 HCV Infection in Young PWID Cases of HCV infection in the younger population of PWID are: More likely to be Caucasian Are located in both rural and urban settings Are approximately equally split among females and males There were 1,990 confirmed opioid-related overdose deaths in 2016 in Massachusetts. This is a 19% increase over 2015 and a 46% increase over Cicero TJ et al, JAMA Psych 2014 MDPH, 2017

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27 Confirmed and Probable HCV Cases Reported in MA by Risk History, 2015 Data source: Massachusetts Department of Public Health, Bureau of Infectious Disease and Laboratory Sciences. Hepatitis C Virus Infection Surveillance Report, Published January Data as of November 16, 2016 and subject to change.

28 Contact Information For data requests and information go to: and type in HCV or call Shauna Onofrey Michael Gaucher For information about HCV services contact Sophie Lewis