May 19, 2016
Credit: bakhtiar_zein for iStock via Thinkstock
May is Hepatitis Awareness Month, which brings needed attention to two leading causes of liver disease and liver cancer: hepatitis B and hepatitis C. In the United States, American Indians and Alaska Natives (AI/AN) have the highest incidence of hepatitis C virus (HCV) infection and the highest incidence of HCV-associated deaths among all racial/ethnic populations. Two papers in the May 12, 2016 issue of Morbidity and Mortality Weekly Report describe how the Cherokee National Health Service (CNHS) and the Indian Health Service (IHS) are marshalling their resources to help people living with HCV get diagnosed and into care and treatment.
In June 2012, the IHS implemented an HCV testing program focusing on baby boomers born in the years 1945-1965, following recent CDC testing guidelines. In three years (from June 2012 to June 2015), the proportion of AI/AN baby boomers screened for HCV increased from 7.9% to 32.5%. The comprehensive testing program included provider education and the use of electronic clinical decision tools to prompt HCV testing of patients in this birth cohort -- two factors associated with the increases in HCV testing. This fourfold increase in testing created challenges with increased need for care and treatment. But the IHS responded and is working to address the additional clinical capacity needed. You can read more about this excellent program here: Birth cohort testing for Hepatitis C virus in the Indian Health Service 2012-2015.
The CNHS initiated, in October 2012, a tribal HCV screening program for recommended groups with a particular focus on baby boomers born from 1945 to 1965. To aid their efforts, CNHS also added a reminder in the electronic health record for clinical decision support and provided HCV education to primary care clinicians. The results have been impressive: HCV testing in the CNHS increased more than fivefold over the three-year study period, the testing coverage among baby boomers was 40%, and HCV treatment more than doubled among Cherokee Nation members. Over half of the approximately 400 patients identified with chronic HCV infection began treatment and 90% of them completed treatment and were cured.
At the same time, approximately 30% of patients found to be HCV antibody positive had not received a confirmatory HCV RNA test and 32% of patients identified with chronic HCV infection had advanced liver disease and needed immediate treatment, highlighting the need to improve laboratory services and expand clinical care.
The Cherokee Nation recently launched The Path towards Elimination of HCV program, with assistance from CDC and others. This program consists of broad-based HCV testing, care, and treatment activities with the goal of treating 85% of CNHS patients with active HCV infection over three years. A second phase of the program will be community based to implement interventions to interrupt HCV transmission.
The Cherokee Nation's HCV elimination program is the first of its kind in the United States. The National Academies of Science, Engineering, and Medicine (formerly the Institute of Medicine) is now examining the feasibility of HCV elimination and outlining a strategy for meeting elimination goals for the entire country. You can read more about the Cherokee Nation's HCV program here: Identification and clinical management of persons with chronic hepatitis virus (HCV) infection in the Cherokee Nation, 2012-2015.
Both of these programs are excellent examples of collaborative public health.
Jonathan Mermin, M.D., M.P.H., is director of the National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention, Centers for Disease Control and Prevention. John Ward, M.D., is director of the Division of Viral Hepatitis, Centers for Disease Control and Prevention.
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