Transcription:

Welcome to UAB MedCast, a continuing education podcast for medical professionals, providing knowledge that is moving medicine forward. Here's Melanie Cole.

Melanie Cole (Host): Welcome to UAB MedCast. I'm Melanie Cole. And joining me, we have a physician panel today, Dr. Ricardo Franco, he's an Associate Professor in Infectious Disease at UAB Medicine; and Dr. David Fettig, he's an Assistant Professor in Gastroenterology and Hepatology at UAB Medicine. And they are here to highlight viral hepatitis and UAB Medicine's Solution for Alabama.

Doctors, thank you so much for joining us today. Dr. Franco. I'd like to start with you. Would you start by telling us a little bit about the state of hepatitis, the scope of the issue we're discussing here today, the prevalence, what you're seeing in the trends, and specifically in Alabama and then around the country.

Dr Ricardo Franco: Sure, Melanie. Thanks for having us. It's a pleasure to be here. Hepatitis C virus is a very common bloodborne infection in the United States. It's also a major cause of morbidity and mortality from liver complications. It's very common in US. About 1% of the population nationally is infected with hepatitis C virus. We have the same reality in Alabama comprising about 40,000 people living with hepatitis C in our state.

Hepatitis C has had much greater prevalence even back in the '90s and early 2000s; when eventually a little after 2010, we developed better medicines to cure hepatitis C and we see a dent in the hepatitis C prevalence from 2015 to 2018 just to see this disease making a comeback, especially right before the pandemic and throughout the pandemic. And this comeback of the disease was fueled by the opioid epidemic and injection drug use. It remains a very important problem. We have the tools to cure the disease. We have expanded services, we have expanded outreach, but it's a disease that has been relentless and disproportionately affecting our most vulnerable populations.

Melanie Cole (Host): Thank you so much, Dr. Franco. And Dr. Fettig, why is it known as the silent killer? Tell us a little bit about the case definitions for reportable hepatitis C virus infections, as far as when we're figuring out the prevalence, as Dr. Franco said. What are we reporting?

Dr David Fettig: Yeah. So, thanks again for having me as well. The reason we kind of talk about it like it is the silent killer is that it takes usually between two and three decades for it to have some sort of an effect on a patient. Sometimes they don't know for even longer than that. And so, when people are actively using, whether like in the current era, kind of actively using IV drugs, taking a long time for that to happen for them to start showing signs of an infection, you can see where a lot of the damage can already be done.

I think that's a grave and difficult question as far as like reportable, just because it's always dependent on who's being screened. And so, based off screening purposes, initially it was all based off of the Baby Boom generation 1945, 1965 due to various reasons, whether that was IV drugs or actually blood transfusions causing disease. Well, now, it's really anybody that's above 18 years of age. And so, getting people in to be screened is kind of the key. So while we see what the current prevalence is, and you could see in the early 2000s, it started to decrease. And then, around like 2009, 2010, it started to start to increase as where we see it today and as it begins to increase. And so, I think with getting people screened, obviously that's going to, I think, increase. And so, I don't think we accurately have that information. But with the awareness and stuff like this, things will get better.

Dr Ricardo Franco: Hepatitis C surveillance, as you would be maybe surprised to learn, is a very difficult thing to do. So, to really get real numbers of people infected and who are screened, who are linked to care and who are treated, is actually labor-consuming, expensive and our health departments have been traditionally underfunded to do this work. So when we say that about 1% of the population is infected with hepatitis C, that comes from databases where we take our best estimates, but we don't have a way to really track real time numbers or real world experience on a global scale or national scale or even statewide scale to say with confidence what the real numbers are. But we have very good estimates, but they're not actual real numbers.

Melanie Cole (Host): Well, thank you both for that. So then, Dr. Franco, based on what you just said and what Dr. Fettig was speaking about, who should get screened? Are there guidelines for screening? So then how would we know?

Dr Ricardo Franco: So as David said, the screening nowadays is to test at least once in a lifetime every adult older than 18, and test regularly adults that are at risk of acquiring hepatitis C. For example, injection drug users that are not already infected with hepatitis C, they should be screened regularly. Most of often, once every year would be a reasonable timeframe and should be regular screening of groups that are at most risk of acquiring hepatitis C. These recommendations they actually changed over time.

Back in the late '90s, we would only recommend the screening for the ones that are at most risk. That eventually evolved when we learned that hepatitis C was three or four times more common among Baby Boomers than in the general population. We expanded the screening to recommend the screening of Baby Boomers. And then eventually, when we saw an emergence of hepatitis C in women of childbearing age because of the opioid epidemic and the spread of the disease in the younger groups, we also pushed for recommendations for prenatal screening, so every pregnant woman would have the opportunity to have this diagnosis and be linked to care after having their babies. And eventually, the CDC expanded these recommendations further to include every adult that should be screened for hepatitis C, which emulates somewhat recommendations in other countries, like France and others, who have spearheaded this more liberal way of finding a disease. And as we found it, do a test and treat approach and treat them with curative medicines.

Melanie Cole (Host): Dr. Fettig, tell us a little bit about the clinical presentation, the first signs and symptoms. What would send patients to their primary care or to the ER or to a specialist such as yourself? What would send the patients to see somebody?

Dr David Fettig: I think that's hits back on this whole screening issue and that it can be silent for long periods of time. So, sometimes nothing. There is an entity of acute hepatitis C that you actually get infected within six to 12 weeks actually begin to have significant symptoms of fever, jaundice, itching, lethargy, fatigue, almost like a similar presentation, I think, to acute hepatitis B, so B as in boy. But typically, maybe nothing. So, it could be as mild as fatigue. You could have some potential skin changes and rashes, arthritis-type symptoms. But otherwise, there may not be anything present. And because of that, I think is where a lot of the screening potential is there for us, as Ricardo had mentioned, for curative therapy.

Melanie Cole (Host): It's one of the biggest challenges, I see. So Dr. Franco then, following up on that, how has UAB taken the lead in getting people tested? Tell us about UAB Medicine's Solution for Alabama.

Dr Ricardo Franco: I'm glad you're asking this question. David and I, we've seen UAB efforts in the forefront of trying to control Hepatitis C for the past 10, 15 years. And I would like to maybe highlight three programs that we put forward in this timeframe. One has been led by the emergency department from Dr. Galbraith to Dr. Walter nowadays. The emergency department has screened over a hundred thousand patients coming through their doors for other reasons to receive emergency care. And they implemented in a nurse-led model, all hands on deck, outstanding team effort to rescreen such a large number of individuals in a population that has an extremely high screening yield.

So for you to have an idea, when we do hepatitis C screening in our vulnerable populations that don't have regular care and use the emergency room as a safety net, the prevalence of hepatitis C screening is well over 5%. Among Baby Boomers, it has been consistently over 10% of antibody positivity for this infection. Whereas if you go to regular clinics, that screening yield might be much less than 1%. So, we have a ten-fold high-yield screening when we go and test the right populations. And the UAB Emergency Department has been leading this effort for years and it has been replicated in other places, and they have joint forces. And they have proven that nationwide this screening strategy is very effective in finding cases and linking them to care and eventually treatment.

Another strategy we implemented, and it's one that gives me a lot of joy to talk about, is the community outreach. We have partnered with the federal-qualified health centers, most of them in our state, to actually train their providers in hepatitis C screening, linkage to care and treatment at their own clinics. We identified hepatitis C champions, we trained them. And what we saw is that even though maybe in a clinical body of 10, 15 providers, if only two of them would take on the duties of treating their own hepatitis C patients for the whole clinic, we saw that actually testing got better clinic-wide. So all the providers, once they learned there is a champion embedded in their own setting, they felt it would be better to test more effectively and find a greater number of cases in their own patient panels. This is also the population served by federal-qualified health centers, a high screen yield population, very vulnerable, where Hepatitis C is highly prevalent with similar prevalences that we see in emergency department close to 5% and 10%. And the third initiative, I'll let Dr. Fettig lead this one. David, you're welcome to talk about our nested model that we combine hepatology and infectious diseases. Please go ahead.

Dr David Fettig: So, I think, Ricardo, I'll just echo a lot of what he said. He'll be very modest about this, but he really took the lead on this at our institution as far as what he's describing. He put in a lot of work and talked with a lot of people to get a lot of these programs running and continue to do that when I came here. But I think we really wanted to have a multidisciplinary approach to this. And the more people that I talk to around the nation, I don't know that anyone in the US is doing quite exactly what we're doing and what we're describing.

So at UAB, we came up with a model that incorporates somebody like myself as a transplant hepatologist and then somebody with infectious disease experience. So, our clinic provides a really vast array of possibilities, and I say that possibilities of diagnoses that could come in. So, HIV co-infection, people with combined hepatitis B, hepatitis C, people with liver masses, people with decompensated cirrhosis, people with compensated cirrhosis, people with no liver disease that can be found other than having the virus present, a lot of different possibilities. And there's actually a place for everyone here. And what's nice about that is we have so many different avenues to get them in, link them to care, and then get them to where they need to be. Whether that would maybe even for the first time, having somebody diagnosed with HIV, well, now we have Dr. Franco that can follow them long-term. Hepatitis B and cirrhosis and liver masses, well, that's something I take care of. Or maybe we need to have this person go for a transplant evaluation, well, that comes out of this clinic. And so, we have so many different possibilities to link them into care. And that multidisciplinary approach, to my knowledge and the people I've talked to, has not been done. And then, going out into the community as we're doing and talking to different providers and helping them with whether that be testing, whether that be treating, knowing who should come to us for treatment. And then, we also have a full-time pharmacist on staff that helps us. We have a full-time administrator who helps call all the patients, helps set up the laboratory results, helps discuss with them, and make sure that their appointments are set. We're going to be doing some different outreaches as far as providing transportation to and from the clinic.

So, what we're doing at our institution really is saying, "Hey, we have a problem in our state as far as a disease and we want to fix it." And so, there's a lot of discussion at times with different things that people do. But Dr. Franco and myself wanted to take action. And so, the clinic is called the ABC Clinic, that is something I think novel and something we're really excited and proud of.

Melanie Cole (Host): That's excellent. And I'm so glad you both highlighted that fact that you represent different specialties, but through the combined clinic, the largest benefits and how you are all working together for this multidisciplinary team approach for these patients is so important. Dr. Franco, tell us a little bit about the success rate of current treatments and how has it really evolved over the years? Because I think, you know, it used to have a bad rap, these kinds of treatments. But now, as you both have alluded to earlier in the podcast, these treatments are much easier and have greater success.

Dr Ricardo Franco: Yes, absolutely. What happens is that the new treatments can cure the vast majority of patients with chronic Hepatitis C. They have efficacy rates well above 95%. They're easy to take. They have very few side effects. Their rates of discontinuation because of bad side effects are close to none, and they can be taken in the short periods of times between two and three months.

That being said, when we go out in the community and you tell your trainees, your nurse practitioners, your physician assistants, your primary care physicians, all working in federal-qualified health centers, and seeing large amounts of patients with chronic hepatitis C when you tell them that these medicines can cure most of your patients, that they're very easy to use, we still have to do this in the right way. You have to make sure that they're following guidelines. You have to make sure they're not dealing with exceptional cases, some of them that David just mentioned. So all that to say, that we're so appreciative to always have transplant hepatology and gastroenterology backup as we do these outreach programs because they're really the ones that give us the backup whenever we see a more complex case, that we have this right way to resort into and get the appropriate care expeditiously and very quickly, and have not only the trainees providing this care, but the patients the right service at the right setting and doing it in a safe way.

So that being said, hepatitis C treatment, it is something that is ready for primetime. And it should be pursued by every single primary care practice in the country. And that's the only way we're going to really control this disease and meet WHO targets of eliminating the disease by 2030. Not to mention that the United States as a whole, they're not on track of key indicators of hepatitis C control, especially controlling incidents because of the opioid epidemic and keep you at pace with the rates of treatment, especially in some of the jurisdictions that have the greatest prevalence and the lowest uptake in treatment because they have large populations that are very hard to reach.

So, that's what makes this whole communion of specialties and innovative service is so important to really get to the patients that they're in greatest need and tackle a very significant disease burden out there.

Dr David Fettig: And I'll chime in as well and add to that. When you really look at hepatitis C history, as far as the treatment goes, I mean, it is really kind of fascinating. I tell people, I say I look back at, I think, it was in the mid-'80s, there was an NIH pilot study that used interferon for non-A, non-B, and that's what they called hep C at the time. And so, the SVR rates were around like 5%. They were really pretty minimal. And so, it's almost as if we went from a horse carriage transportation-wise to the Tesla in this short period of time, which is really phenomenal. So, that's in the '80s, and you go to the early 2000s and, essentially, that's when the DA agents that were talking about to cure hepatitis C. So, it happened in the grand scheme of treatment for diseases, it happened rather fast. Like, there wasn't a whole lot of in between. And I think that's also getting rid of the stigma of the old medications of interferon, which were very difficult. Very, very, very difficult. And to let you know, I've actually never prescribed interferon and I can count on one hand the times I had to prescribe ribovirin as another antiviral for hepatitis C. So, it tells you how new this stuff is and how quickly it happened.

The other thing I'll point out as well is I think the ASLD, that's American Association of Study Liver Disease, as well as the Infectious Disease Society of America teamed up. And on the ASLD website, just kind a plug for them. They have a really nice approach for management of hepatitis C testing. And it's very simple. It's very user-friendly. They'll also go into like who is not eligible for simplified treatment. That's kind of what Ricardo and I were talking about, like the champions in the community that are treating it. And so, it really goes over very specifically the do's and don'ts and pretreatment assessment. So, it really makes hepatitis C treatment easy. We also need to understand, it can be difficult at times to do it right. So while it's easy to treat, it can be hard to do it the correct way. And so something like this, as well as our clinic, really provides an answer to both of those question.

Melanie Cole (Host): Thank you both so much. What an absolutely excellent, informative podcast. And thank you both for doing all the great work that you're doing for viral hepatitis in UAB Medicine's Solution for Alabama. Just excellent information. And a physician can refer a patient to UAB Medicine by calling the MIST line at 1-800-UAB-MIST or by visiting our website at uabmedicine.org/physician. That concludes this episode of UAB MedCast. I'm Melanie Cole.