A community-wide hepatitis C elimination campaign in
Seattle, United States, tripled the number of people screened for hepatitis C
and increased the number treated tenfold between 2014 and 2018, doctors and
public health specialists report in the March edition of Hepatology Communications.
Although direct-acting antiviral treatment is recommended for
all adults with hepatitis C in the United States, curing people of hepatitis C
requires a sequence of actions. Screening, delivery of a diagnosis,
confirmation of chronic infections, referral for care, staging of liver
disease, initiation of treatment and confirmation of sustained virologic
response each require specialised interventions, and people can be lost from
care during this process, often described as the cascade of care.
Successful retention of people with hepatitis C throughout
the cascade of care is essential for achieving elimination of hepatitis C. To
move towards elimination in the Seattle region, Public Health of Seattle and King
County Public Health developed the HCV-TAC Coalition, which brought together
three community health centres, three multi-clinic healthcare providers and a
patient education and advocacy group to reach a broad spectrum of Seattle residents.
The campaign had five key elements:
- Screening: Focusing on baby boomers, clinics
introduced electronic medical record flags to prompt hepatitis C antibody
testing in everyone born between 1945 and 1965 or mailed screening reminders to
eligible patients. Posters in clinics advertised screening and encouraged
patients to speak with their healthcare provider about it.
- Training for healthcare providers: an extensive
training programme used telemedicine, online tutorials and in-service trainings
to train 252 primary care providers in hepatitis C evaluation and treatment.
- Case management: To ensure linkage to care,
public health departments and the Hepatitis Education project provided support
to ensure that people diagnosed with hepatitis C could navigate from testing to
cure by providing information on medical services and financial aspects of obtaining
- Public awareness campaign: Public health
departments used a range of media to raise awareness of hepatitis C in Seattle.
Targeted outreach to Black and ethnic minority communities and through needle
and syringe programmes targeted groups with potentially high prevalence of
- Data monitoring: public health departments
developed a data monitoring system to track progress through the hepatitis C
care cascade and used data to adjust services.
Between 2013 and 2014, when direct-acting antiviral treatment
was introduced, and 2017 and 2018, 77,577 baby boomer patients were screened for
hepatitis C. The proportion of people in the baby boomer birth cohort screened
for hepatitis C rose from 18% of people who visited a participating clinic in
2013-14 to 54% in 2017-18. The increase in screening was strongly linked to the
introduction of electronic medical record prompts.
Three per cent of those screened tested positive for
hepatitis C antibodies, declining from 8% in year 1 to 2.5% in year 4. Overall,
73% had chronic hepatitis C virus (HCV) infection.
In addition to these patients, 2592 non-baby boomers were
diagnosed with chronic HCV infection, while 3887 with a medical history indicating
hepatitis C but no antibody test were found to have chronic HCV infection.
Altogether, 8720 people were identified with chronic HCV
infection at the participating clinics during the analysis period. Two-thirds
were male, 59% were White and 13% had advanced fibrosis (F3 or F4).
Seventy-nine per cent of those with chronic infection were
assessed for treatment and 53% of the entire chronic HCV population started hepatitis
C treatment. Of those tested for sustained virologic response 12 weeks after
completion of treatment (79%), 95% were cured of hepatitis C. Comparison of the
care cascades in Year 1 and Year 4 show that of 4694 people diagnosed with chronic
infection, just under 6% started hepatitis C treatment and less than 4% were
cured. By Year 4, 52% of people diagnosed with chronic HCV infection (8270)
started treatment and 39% had been confirmed as cured by the end of the period. Overall, the number treated increased by 1263%.
The Seattle project achieved a much greater increase in baby
boomer testing than the US average over the same period, which rose from 12.3%
to 17.3%. The researchers say the success of the project was attributable to
the multiple interventions, the range of partners collaborating on hepatitis C
elimination and the lifting of fibrosis-related restrictions on hepatitis C
treatment in Washington state in 2016.