1. Charlie Howsare, MD MPH Pa. Viral Hepatitis Prevention Coordinator
The Intersection of Overdose, Opiate Use Disorder, and HCV in Pennsylvania 2016
Charlie Howsare, MD MPH
Pa. Viral Hepatitis Prevention Coordinator

2. This is the public health crisis of our generation.

3. The Epidemics Everyday in the Commonwealth: 10 people die of overdose
>17 young adults contract hepatitis C
Women infected with HCV, who do not know their status, are giving birth

4. Sentinel Events 400% increase in HCV in 4 States 2013
HIV/HCV Outbreak in Indiana 2014
Overdose deaths 2015
Tripling of heroin users 2016
150,000 to almost ½ a million

5. 400% increase in HCV in 4 States 2013
Tennessee, Kentucky, Virginia, West Virginia
Oral opiatesInjection of opiatesHeroin
HCV prevalence in using networks 30-70%

6. HCV Infection from Injection Drug Use Behaviors
Injection drug use (IDU) is the principle risk factor for HCV infection
Most reported risk behavior in acute case reporting
HCV prevalence among persons who inject drugs (PWID) between 30% and 70%
HCV prevalence among younger (<30 yrs.) between 10% and 36%
HCV incidence between 16% and 42% per year
Hagan et al. 2010; Garfein et al. 1998; Armstrong et al. 2006; Amon et al. 2008; Klevens et al. 2013; Daniels et al. 2007

7. PA-NEDSS Reported HCV Past and Present by Age Group

8. Changes in Demographics PA
2003
2007

9. Changes in Demographics PA
2010
2014

10. GIS Mapping of HCV Age-Specific per 100,000 for the 15-35 year old demographic

11. HCV in Young Adults in Pennsylvania 2003-2015

12. 190 people in this Indiana town were diagnosed with HIV April 10, 2016
“Now, a year later, the outbreak is at 190 cases. But the sickness runs deeper. Poverty envelops this city. Empty storefronts dot the main street. Many homes are boarded up or have makeshift tarps instead of windows. Fewer than 10% of Austin's residents have earned a college degree. One out of five residents lives below the poverty level, more than 1.5 times the rate in Indiana. Drug use here is still rampant.”

13. 190 people in this Indiana town were diagnosed with HIV April 10, 2016
“Some users shoot up alongside their children or even their children’s children. In the winter, as many as 20 users may huddle in a home, gathering in the one building that has heat for the day.”

14. More Consequences
On track with the heroin crisis, the number of children in foster care in Pennsylvania has leapt in three years, reaching 15,995 at the end of 2015, state statistics show. That’s a 14 percent increase from the 14,004 of 2012.
In one of those years, 2014, parental substance abuse was a factor in more than 56 percent of the cases in which infants were removed from their homes, according to the Center for Children’s Justice, a nonprofit in Berks County.
Alongside that, more than 7,500 babies were born from 2010 to 2014 with drug dependencies they received in utero, according to Pennsylvania Medicaid statistics obtained by the children’s justice center. And those were tip-of-the-iceberg numbers that do not account for newborns whose mothers had private insurance, as six in 10 Pennsylvanians do.

16. More Consequences
2691 babies required NICU stays in 2015 (788 required NICU stays in 2000)
60% of the babies required morphine or methadone to get through withdrawl
4615 maternal hospital stays related to substance abuse 2015
52% related to heroin
Average length of stay for addicted babies is 25 days
Source: PHC4

17. More Consequences
For every 100 mothers who have hepatitis C, about six newborns will contract the disease, according to the Centers for Disease Control and Prevention [CDC].
Since transmission rates are low compared to hepatitis B or HIV, hospitals aren’t testing high-risk babies.
8,119 women were reported to Philadelphia’s Hepatitis Registry as HCV positive. Of those, 500 had at least one baby, with 537 total children born during the 2011 through 2013 study period. Just 84 of these children were tested. Four of them were confirmed cases of hepatitis C.
Of the newborns who were not screened, roughly 24 other cases of the virus are expected to develop. But without testing, many will remain unaware of the condition and will not seek treatment until later in life.

18. Treating Opiate Addiction

19. Opiate Use Disorder

20. Opiate Use Disorder

21. Opiate Use Disorder

22. Opiate Use Disorder (OUD)

23. Opiate Use Disorder

24. Opiate Use Disorder

26. Overdose

27. OUD

28. Overdose

29. Overdose

30. Necessary but not sufficient….
Drug Treatment with MAT
Methadone
Suboxone
Harm Reduction
Syringe/works exchange
Naloxone
HCV treatment
Reduce the viral load of the using community

31. Educational Materials

32. Vulnerability Assessment

33. Harm Reduction

34. Framework of a model HCV control strategy for PWID
Prevent new infections
Detect and care for existing infections
Reduce chronic infections
HCV prevention activities
Access to syringes & other equipment
OST
Safe injection education
Outreach to those not engaged
Screening and diagnosis
Antibody screening
RNA test to confirm
Clinical evaluation to determine disease stage
Monitoring disease progression
Reduce alcohol use
HCV care and treatment
Treat to cure infection
Support adherence to treatment
Support post-cure to prevent reinfection
Co-locating these services increases their impact on HCV control
Provided by Holly Hagan

35. Our Challenge
How do we keep people alive, and uninfected with HBV, HCV, and HIV until they can get into drug treatment that allows treatment integrity and offers opiate substitution therapy with ongoing support through early recovery?

36. Summary Everyday in the Commonwealth: 10 people die of overdose
>17 young adults contract hepatitis C
Women infected with HCV, who do not know their status, are giving birth