Update on HCV and other infections related to injection drug use Ann Thomas, MD, MPH Acute and Communicable Disease Prevention Dec 14, 2018
Overview Update on NHANES prevalence data Trends in HCV, HIV and syphilis in OR Other health indicators in PWIDs HCV screening and treatment 2
Prevalence of HCV in the US NHANES, 2003-10 vs 2013-16* Millions of Americans 4.5 4 3.5 3 2.5 2 1.5 1 0.5 0 4.1 3.6 2.7 2.4 2003-2010 2013-2016 HCV Ab+ RNA + *2013-16 estimates include: incarcerated individuals nursing home residents unsheltered homeless active-duty military Denniston, et al. Ann Int Med 2014;160:293-300 Hofmeister, et al. Hepatology https://doi.org/10.1002/hep.30297 3
Numbers and age-adjusted rates of HCV-related deaths, Oregon 2010-2017 Numbers of deaths 600 500 400 300 200 100 400 425 434 545 550 500 478 504 12.00 10.00 8.00 6.00 4.00 2.00 Age-adjusted rates/100,000 0 2010 2011 2012 2013 2014 2015 2016 2017 0.00 Number Rate
Rates of Chronic HCV cases in persons < 30, Oregon, 2012-2016 60.00 HCV <30 50.00 40.00 30.00 20.00 10.00 0.00 2012 2013 2014 2015 2016 PDX Rest of OR 53% increase in cases under 30 years of age
Rates of new HIV diagnoses in Oregon 2012-2016 14.00 12.00 10.00 8.00 6.00 4.00 2.00 0.00 2012 2013 2014 2015 2016 Rest of OR PDX Area 18% drop in cases statewide between 2012 and 2016
Rates of HIV deaths, Oregon 2012-2016 4.50 4.00 3.50 3.00 2.50 2.00 1.50 1.00 0.50 0.00 2012 2013 2014 2015 2016 PDX Rest of OR 17% drop in deaths statewide between 2012 and 2016
Rates of early syphilis Oregon, 2012-2016 30.00 25.00 20.00 Year Congenital Syphilis Cases 15.00 10.00 5.00 0.00 2012 2013 2014 2015 2016 PDX Rest of OR 2013 0 2014 2 2015 6 2016 6 2017 8 2018 11 91% increase statewide, from 310 cases to 591cases
Proportion of cases reporting injection drug use, Portland area vs rest of Oregon, 2012-16 90 80 85 70 65 60 50 40 35 42 30 20 17 22 18 21 10 0 HIV cases HIV deaths Acute HCV Syphilis PDX Rest of OR 9
Hospitalizations due to IDU-related bacterial infections, by infection type, Oregon IDU-Related SBI Hospitalizations (n) 3,000 2,500 2,000 1,500 1,000 500 0 2008 2009 2010 2011 2012 2013 2014 2015 Endocarditis Bacteremia Sepsis Osteomyelitis Skin\Soft Tissue Infection 10
Total annual costs* of IDU-related SBI Hospitalizations, Oregon $250,000,000 $218,987,964 Cost in 2015 dollars $200,000,000 $150,000,000 $100,000,000 $50,000,000 $69,385,527 11 $0 2008 2009 2010 2011 2012 2013 2014 2015 *Adjusted for charge-to-cost and inflation (2015 USD)
Increases in numbers of cases of GAS, Portland Tricounty area, 2010-2017 Invasive Group A Streptococcus by High Risk Group 50 45 40 35 30 25 20 15 10 5 0 2010 2011 2012 2013 2014 2015 2016 2017 PWID Homeless PWID & Homeless In 2017, 57% of cases if invasive GAS were either PWID, PEH or both
Numbers of cases of candidemia, Portland Tricounty area, 2014-18 120 Number of cases 100 80 60 40 20 0 2014 2015 2016 2017 2018* non-pwid 56 45 48 73 45 PWID 14 19 19 24 12 *2018 data collection incomplete
Percent of candidemia cases in PWID by surveillance site, 2017, n=1221 Proportion of Cases who Inject Drugs (%) 30% 25% 20% 15% 10% 5% 0% 7.8% 4.8% 3.9% 16.7% 1.4% 29.4% 8.6% 25.8% 16.3% CA CO GA MD MN NM NY OR TN Overall proportion in PWID = 10.5% 14 14
Rates of Neonatal Abstinence Syndrome (NAS) per 1,000 live births, Oregon, 2012-16 Rates per 1,000 live births 8.00 7.00 6.00 5.00 4.00 3.00 2.00 1.00 0.00 N=278 N=214 2012 2013 2014 2015 2016 Portland Metro Area Rest of Oregon 37% increase in rates between 2012 and 2016 15
Rate of women with HCV reported on birth certificate (per 1,000 live births) Oregon 2008-2016 4.5 4.0 3.5 3.0 2.5 2.0 1.5 1.0 0.5 0.0 2008 2009 2010 2011 2012 2013 2014 2015 2016 16 Snodgrass, MMWR 2018;67:201-2 16
Baby Boomer Screening In 2012, CDC implemented recommendation for onetime screening of individuals born between 1945 and 1965 National Health Interview Survey estimated that only 13.8% had been screened in 2015 in the US, 3 years after the CDC and the US Preventive Services Taskforce made the recommendation 17 Jemal. Am J Prev Med 2017;53:e31-e33
Proportion of persons ever tested for HCV by age group and gender, Oregon 2017 Percent 50 45 40 35 30 25 20 15 10 5 0 22.5 19.2 17.4 19.3 8.8 4.2 Born before 1945 Born 1945-1965 Born after 1965 Male Female 18
Severe Outcomes of HCV, Oregon Medicaid Patients, 2009-13 Identified cohort of Oregon residents with HCV enrolled in Medicaid at least 12 mos Cross-matched data set with hospital discharge, OSCaR, and death certificate databases 19 Estimate incidence of advanced liver disease (hospitalization with cirrhosis, varices, hepatic encephalopathy, etc), liver cancer, and deaths (underlying cause of death=hcv or advanced liver disease)
Severe Outcomes of HCV, Oregon Medicaid Patients, 2009-13 Of 11,790 Medicaid beneficiaries with HCV: 156 (1.3%) with hepatocellular carcinoma 596 (5.1%) initial hospitalizations for advanced liver disease 474 (4.0%) HCV-related deaths Only 262 (2.2%) ever initiated treatment with antivirals Jindai. Public Health Reports:https://doi.org/10.1177%2F0033354918813552 20
HCV Care Continuum, Oregon 2015 100,000 90,000 Diagnosed\Undiagnosed estimate 90,500 80,000 70,000 Reported and living, 2015 68,985 60,000 50,000 40,000 In care, 2011-2015, 39,210 30,000 20,000 10,000 0 57% 8% Initiated antiviral HCV treatment, 2011-2015, 3,329 21 Sources: CDC, Hepvu.org, Orpheus, 2011-2015 (May 26, 2017), and Oregon APAC, 2011-2015
Oregon HIV Care Continuum, 2016 9,000 8,000 Number of Oregon residents 7,000 6,000 5,000 4,000 3,000 2,000 Diagnosed, 7,157 88% In care, 6,269 On treatment, 6,081 97% Suppressed, 5,463 95% 1,000 0 Diagnosed In care On treatment Suppressed Source: Oregon HIV Program, ORPHEUS and CAREAssist enrollment, 2016 22
Age-adjusted Death Rates for HCV and HIV, Oregon, 1993 2013 12.00 Age-adjusted rate per 100,000 10.00 8.00 6.00 4.00 2.00 Advent of HAART HCV HIV HIVHCV 0.00 How antiretroviral treatment changed the curve for HIV
Summary Increasing burden of infectious diseases among PWIDs But, Oregon has new opportunity to make a difference in trajectory of HCV epidemic Still, need to work to improve availability of harm reduction services, SEP, MAT, naloxone, wound care services 24
Questions 25