Experts release new recommendations for the elimination of HCV in the U.S.

A recent report from the O’Neill Institute for National and Global Health Law at Georgetown University provides key recommendations for the potential elimination of hepatitis C in the U.S., based upon an expert consultation of 35 diverse stakeholders, including HCV medical and non-medical providers, patient advocates, epidemiologists, and federal HCV policy and program staff.

“To eliminate HCV in the U.S., we must effectively monitor the epidemic and deploy critical public health and health care resources to prevent new infections, screen and diagnose cases, and treat all of those who are infected with the virus,” Sonia L. Canzater, JD, MPH, and Jeffrey S. Crowley, MPH, from Georgetown University wrote in their report. “While expanding access to care and treatment and bolstering the health care workforce are also critically important, these efforts will not be as effective as they could be if we do not have sufficient data to inform our efforts.”

The report, “Monitoring the Hepatitis C Epidemic in the United States: What Tools are Needed to Achieve Elimination?”, discusses the current rates of HCV infection and identifies new policies and actions that would strengthen the effort to eliminate HCV in the U.S.

According to Canzater and Crowley, eliminating HCV in the U.S. is possible with improved surveillance and monitoring. There are currently 40 states that provide acute HCV case report data to the CDC, but due to resource limitations only 14 jurisdictions are currently funded to provide more detailed surveillance data.

“Strategic investments are needed to realize the potential to treat and cure all people living with HCV,” the researchers wrote. “This would yield enormous benefits by producing a healthier population and avoiding preventable health expenditures associated with treatment of liver disease and organ transplantation.”

The researchers found that only 2,194 of 30,500 acute HCV cases determined in 2014 were directly reported to the CDC, of which 1,030 patients were specifically asked about injection drug use (702 reported using within 2 weeks to 6 months of illness onset), leaving 1,164 patients who had no response to risk behaviors or exposures reported.

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Canzater and Crowley presented the following key recommendations.

Expand and standardize reporting to the CDC

The researchers implore policy makers to expand surveillance of HCV in more states and territories and to work with local jurisdictions in areas with high rates of infection. The Division of Viral Hepatitis (DVH) of the CDC needs new resources to strengthen screening and diagnosis as well as funds for modeling studies, surveys and algorithms to estimate HCV incidence.

This could be achieved by congressional appropriators working with the DVH. Together, a five-year plan to bolster the capacity for conducting active surveillance should be developed, including a standardized rubric that requires clinicians to report necessary details of patient information. This information could then be provided to whichever state would best be able to use and compare the available data.

Use electronic medical records to collect data on HCV cases and the cure cascade

An integrated, centralized electronic medical records database would improve consistency, quality and accuracy of case reports, lessening the burden on providers’ and laboratories’ limited time and resources to report new cases to state health authorities under current requirements.

This follows a principle recommendation made by the National Academies of Sciences in their Phase Two Report on the nation’s Hepatitis Elimination Strategy. Additionally, Massachusetts Technology has developed some pilot initiatives to extract, compile and analyze public health data into from electronic medical records.

Fund epidemiologic research using clinical data sets

As there already exists a significantly untapped resource of clinical data, the U.S. Department of Health and Human Services should work with its agencies to develop an inter-agency process of identifying high priority research questions and coordinate research.

Additionally, the researchers recommend that agencies outside of the HHS, such as the Department of Veterans Affairs and Department of Defense, as well as major health care programs such as Medicaid and Medicare, should be integrated into the proposed access systems to use all potentially available clinical data.

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Integrate improved monitoring of HCV with responses to the opioid epidemic

“The Nation is increasingly recognizing the breadth of the public health crisis we are facing related to the opioid abuse,” Canzater and Crowley wrote. “Indeed, drug overdose deaths have been rising dramatically. By 2009, more Americans died each year from drug overdoses than from automobile accidents. The majority of these deaths are attributable to opioid abuse. Encouragingly, many stakeholders are beginning to respond and the Administration has pledged new resources to respond to this crisis.”

As national efforts focus on substance abuse prevention and treatment, particularly in relation to the spread of HIV, HCV must be elevated as a signature component of the national response to opioid abuse as well.

Establish and monitor HCV elimination plans across major U.S. health systems

Following the example of HIV prevention plans seen in several states and local jurisdictions, similar strategic plans are needed to eliminate HCV in the U.S.

Two examples of such plans are the Cherokee HCV elimination project, which has screened 23,000 patients in the program’s first year and includes plans to screen 85% of the Cherokee nation by 2018. There is also the Veterans Health Program, which has lead the way toward eliminating HCV among veterans.

Correctional systems, however, are an example of a population that requires greater focus in the effort to eliminate HCV in the U.S. “Federal policy makers should be tasked with developing an elimination plan for the Bureau of Prisons, as well as devising strategies for inducing and supporting state and local efforts to monitor and work toward HCV elimination within each state’s correctional system,” the researchers wrote.

Conclusion

“HCV is a serious public health threat. Recent treatment advances and increased attention on the opioid epidemic create new opportunities for progress and demand new efforts to appropriately allocate prevention and treatment resources where they are most urgently needed,” Canzater and Crowley concluded their report. “Unlike some pressing problems where the scope of need is so large it can be immobilizing, modest new investments can have a significant impact. Boosting the capacity to monitor the HCV epidemic can move the Nation toward eliminating HCV as a public health threat in the United States.” – by Talitha Bennett

Reference: Canzater S, Crowley JS. Monitoring the hepatitis C epidemic in the United States: What tools are needed to achieve elimination? http://www.law.georgetown.edu/oneillinstitute/research/HepatitisCEpidemic.cfm. Published June 2017. Accessed June 16, 2017.