The Tool Box

Oregon Viral Hepatitis Elimination Plan

The Oregon Viral Hepatitis Program has developed a draft viral hepatitis elimination plan based on input obtained from Oregon’s Viral Hepatitis Collective.  We are now soliciting input and feedback on the plan from a wide range of community partners and key stakeholders.  The basic framework of the plan involves four pillars that are accessible through the SurveyMonkey links at the end of each section.

Goals

Our four overarching goals align with national objectives and match goals identified by Oregon’s Viral Hepatitis Collective, which completed a statewide viral hepatitis planning process in 2016.

Objectives

Objectives focus on key outcomes and key process points and are outlined for each overarching goal.

Strategies

Strategies suggest ways to meet objectives and can be measured to ensure that we stay on track to meeting our goals by 2030.

We want your opinion on the proposed strategies and to hear about what we are missing. 

  • Which strategies do your agency or healthcare facility already employ?
  • Which of these strategies could your agency or healthcare facility implement?
  • Do you have any ideas for additional strategies?

We invite you to review each section of the plan and provide feedback on the proposed strategies. As you review each of the 4 pillars, we have boxes at the end of each survey where we would love to hear your thoughts. Also, please feel free to forward the plan to any of your colleagues who might be interested in reviewing the plan.

We look forward to incorporating everyone’s ideas into a plan that moves us closer to elimination of hepatitis in Oregon. Thank you for all your hard work and commitment. If possible, please return your comments via Survey Monkey by December 20.

GOAL 1: PREVENT NEW HEPATITIS INFECTIONS

Recent trends in Oregon

  • Between 2016 and 2020 in Oregon, new cases of hepatitis A virus (HAV) and hepatitis B virus (HBV) were highest in people over the age of 30, while new cases of hepatitis C virus (HCV) were most common in people aged 20-29 years.
  • Rates of cases of chronic HCV in people under 35 have been increasing steadily and occur primarily in people who inject drugs (PWID).
  • Of children born to mothers with HBV in 2019 and 2020, 88% received vaccine prophylaxis at birth and 78% finished the 3-dose series within 8 months.

Rationale for Proposed Objectives and Strategies

Harm Reduction Strategies

  • Currently there is no vaccine for HCV, so the most important way to prevent new HCV infections is to increase accessibility of harm reduction services and treatment of opioid use disorder (including medications for opioid use disorder [MOUD]).
  • The combination of syringe service programs (SSPs) and substance use disorder treatment programs can prevent 75% of new infections.

Vaccination

  • Safe and effective vaccines for HAV and HBV have been available for over two decades and are routinely given to infants, children, and high-risk adults.
  • However, HAV and HBV vaccination rates are much lower in adults over age 30, since the vaccines were not available when they were children.
Goals 1. Prevent new hepatitis infections
Objectives 1.1 Expand availability of harm reduction services

1.2 Increase HAV[1] and HBV[2] vaccination rates 

Secondary Objectives

1.1.1 Expand harm reduction in healthcare and community settings 

1.2.1 Increase vaccination of high-risk adults
1.1.2 Improve hygiene and sanitation for persons experiencing houselessness (PEH) 1.2.2 Increase update of HBV vaccine birth dose for newborns
1.1.3 Use of MOUD and substance use disorder (SUD) treatment in people who use drugs 1.2.3 Support routine vaccination of children

Objective 1.1 Expand availability of harm reduction services

Strategies

1.1.1 Expand harm reduction options in healthcare and community settings

  • Expand number of syringe services programs (SSPs) as well as operating days and hours in every county
  • Expand use of peer recovery specialists in the community, healthcare settings, behavioral health, and MOUD/SUD treatment settings to promote harm reduction
  • Improve access to harm reduction supplies in pharmacies, emergency departments, healthcare clinics, SUD and MOUD clinics, as well as community settings such as food pantries, bottle drops, houseless encampments, and through free harm reduction vending machines
  • Increase availability of syringe disposal in pharmacies, emergency departments, schools, and community settings

1.1.2.  Improve hygiene and sanitation for persons experiencing houselessness (PEH)

  • Increase access to toilets, soap and running water
  • Provide garbage disposal services at houseless camps
  • Increase access to mobile laundry and showers
  • Increase access to surface disinfectants, hand sanitizers, and disposable wipes
  • Connect PEH clients to Behavioral Health Resources Network (BHRN) providers in their community

1.1.3 Increase access to MOUD and substance use disorder (SUD) treatment in people who use drugs

  • Provide training to primary care providers to deliver MOUD treatment
  • Scale-up implementation of peer supported interventions to increase access to MOUD/SUD treatment
  • Assist people leaving carceral settings to access MOUD and SUD treatment through use of community health workers (CHWs), peer recovery specialists, and coordinated care organizations (CCOs)
  • Increase telemedicine options for MOUD
  • Provide training to primary care and obstetrical providers to conduct provide harm reduction counseling and prescribe naloxone

Objective 1.2 Increase HAV and HBV vaccination rates

Strategies

1.2.1 Increase vaccination of high-risk adults

  • Recruit and maintain a network of public and private providers to administer

Section 317- and state-funded (if applicable) vaccines to eligible adult populations.

  • Promote routine vaccination for Hep B for all adults 19-59 and adults over 60 with risk factors in clinical settings
  • Increase vaccination rates in carceral settings, adult community-based facilities serving people with psychosocial disabilities, and among persons experiencing homelessness
  • Promote educational programs for high-risk adults to increase vaccine confidence
  • Increase vaccination of high-risk adults accessing behavioral health and substance use disorder settings, pharmacies, dentists, health fairs and community outreach settings such as SSPs

1.2.2 Increase uptake of HBV vaccine birth dose for newborns

  • Train providers on increasing vaccine confidence in pregnant women
  • Develop education for providers and families on importance of newborn dose of HBV vaccine
  • Provide case management of infants born to HBV-infected mothers to ensure appropriately timed doses of vaccination and follow-up testing
  • Monitor HBV vaccine administration data in the state immunization registry to monitor coverage of infants
  • Address system changes to assure birth dose administered at the hospital by increasing the number of birthing hospitals that track HBV birth dose coverage and are enrolled as Vaccines for children (VFC) providers

1.2.3 Support routine vaccination of children

  • Recruit and maintain a network of public and private providers to administer:
    VFC vaccines to program-eligible populations
  • Section 317- and state-funded (if applicable) vaccines to eligible pediatric populations.
  • Promote educational programs for parents to promote vaccine confidence
  • Monitor hepatitis vaccine administration coverage of infants, children, and adolescents in the state immunization registry

[1] Hepatitis A vaccine information statement from CDC
[2] Hepatitis B vaccination of adults from CDC

Provide your feedback to OHA HERE

GOAL 2: IMPROVE HEALTH OUTCOMES

Recent trends in Oregon

  • Each year between between 2016 and 2020 Oregon averaged:
    • 5,240 newly reported cases of chronic HCV and 404 cases of chronic HBV
    • 2,165 hospitalizations related to HCV and 194 to HBV
    • 460 deaths related to HCV and 32 from HBV
  • Although rates of HCV screening and treatment rose dramatically between 2011 and 2019, fewer young adults received treatment than baby boomers.

Rationale for Proposed Objectives and Strategies

  • CDC now recommends one-time universal screen of all adults for HBV and HCV, screening with every pregnancy, and repeated screening of people at high risk. [1],[2]
  • New generation of HCV direct-acting antivirals (DAAs) are safe, simple, and highly effective at curing HCV in most people.
  • Treatment of people who actively inject drugs reduces transmission among people most likely to spread HBV and HCV.
  • Although not curative, treatment for HBV reduces viral load and lowers the risk of transmission and conditions such as liver cancer and cirrhosis.
Goals 2. Improve Health Outcomes
Objectives 2.1 Increase screening and diagnosis of HBV and HCV 2.2 Increase treatment/monitoring of chronic HCV 2.3 Increase treatment/monitoring for chronic HBV
Secondary Objectives 2.1.1 Implement universal one-time screening of persons > 18 years for HBV and HCV 2.2.1 Increase number of patients diagnosed and linked to HCV care 2.3.1 Increase number of patients diagnosed and linked to HBV care
2.1.2 Increase screening of pregnant women and children exposed to mothers with viral hepatitis during pregnancy 2.2.2 Increase number of primary care providers (PCPs) providing HCV treatment 2.3.2 Increase number of PCPs who can facilitate treatment of Hep B and provide long term management, such as screening for liver cancer
2.1.3 Increase periodic screening for people with ongoing risk factors 2.2.3 Increase patients with chronic HCV who are linked to medical home 2.3.3 Increase number of patients with chronic HBV who are linked to a medical home

Objective 2.1 Increase Screening and Diagnosis of HBV and HCV

Strategies

2.1.1 Implement universal one-time screening for persons > 18 years for HBV and HCV

  • Implement opt out one-time HBV/HCV/HIV screening of adults in healthcare systems
  • Ensure all labs/health systems conduct automatic reflex HCV RNA testing on specimens positive for anti-HCV antibodies
  • Promote clinician training on new recommendation for universal screening for HBV
  • Encourage use of clinical decision support tools and quality improvement initiatives to improve adherence to HBV and HCV screening guidelines

2.1.2 Increase screening of pregnant women and children exposed to mothers with viral hepatitis during pregnancy

  • Standardize HCV screening as part of prenatal lab panel and as part of admission to labor and delivery if not done during pregnancy
  • Educate pediatric providers about need to screen infants born to mothers who were HCV positive during pregnancy
  • Promote use of clinical decision support tools to track infants born to women found to be positive for HCV during pregnancy to ensure appropriate testing and follow-up by age 18 months
  • Screen infants exposed to HBV 1-2 months following third dose of HBV vaccine
  • Document pregnancy status on labs positive for HBV or HCV

2.1.3 Increase periodic screening for people with ongoing risk factors

  • Increase screening at community sites, health fairs, and outreach programs serving PWID, such as SSPs, houseless camps and shelters
  • Increase availability of dried blood spot testing to ensure quick access to results and minimize loss of follow-up
  • Develop media campaigns around the importance of screening and availability of treatment for HBV and HCV
  • Promote opt out onsite HBV/HCV screening for those accessing behavioral health or substance use disorder/opioid treatment programs
  • Promote opt out HBV/HCV screening in carceral settings
  • Offer HBV and HCV screening in high-risk settings wherever HIV and STI screening is routinely performed

Objective 2.2 Increase treatment/monitoring of chronic HCV

Strategies

2.2.1 Increase number of patients diagnosed and linked to HCV care

  • Expand use of telemedicine to expand HCV treatment to the entire state, including non-traditional care settings such as SSPs, MOUD and SUD treatment centers
  • Promote use of peer recovery specialists or peer navigators in both community and healthcare settings to facilitate linkage to care and improve adherence to medications among high-risk patients
  • Promote cross-systems collaboration to treat HCV among people with all forms of disability, including psychosocial disability
  • Promote use of clinical decision support tools and quality improvement projects in healthcare settings that assure diagnosis and linkage to care
  • Initiate same day treatment for individuals with confirmed HCV
  • Ensure that treatment for HCV continues during periods of incarceration

2.2.2 Increase number of providers administering HCV treatment

  • Promote awareness of high effectiveness and ease of treatment with DAAs among all clinicians
  • Provide trainings in collaboration with OHSU’s Extension for Community Healthcare Outcomes (Project ECHO) and the AIDS Education and Training Center (AETC) for primary care providers (PCPs), allopathic and non-allopathic, on HCV treatment
  • Encourage health systems to provide clinician education on HCV treatment as part of mandatory trainings or continuing education
  • Implement “clinic champion model” (designated PCPs trained to treat HCV) within all primary care systems
  • Promote use of specialty pharmacies in linking patients to care, providing HCV treatment in collaboration with PCPs, and tracking treatment outcomes

2.2.3 Increase patients with chronic HCV who are linked to medical home

  • Assure that patients with HCV receive care management, which includes long term management and surveillance for liver disease
  • Offer care navigation in outreach settings to help people at high risk for HCV to enroll in a health plan

Objective 2.3 Increase treatment/monitoring for chronic HBV

Strategies

2.3.1 Increase number of patients diagnosed and linked to care

  • Promote use of clinical decision support tools and quality improvement projects in healthcare settings that assure diagnosis and linkage to care
  • Reduce stigma around diagnosis of HBV through social marketing and storytelling from people with lived experience
  • Promotes use of peer recovery specialists or peer navigators in both community and healthcare settings to facilitate linkage to care and improve adherence to medications

2.3.2 Increase number of PCPs who can facilitate treatment of HBV and provide long term management

  • Expand telehealth support for PCPs managing patients with HBV
  • Provide trainings in collaboration with OHSU ECHO, Indian Country ECHO, and AETC for primary care providers on HBV screening and co-management of treatment with subspecialists
  • Encourage health systems to provide clinician education on HBV co-management and long-term surveillance for cirrhosis and liver cancer

2.3.3 Increase patients with chronic HBV who are linked to a medical home

  • Increase linkage to PCP or medical home from outreach sites with HBV testing
  • Assure that patients with HBV receive care management or patient navigation services, which includes long term management and surveillance for liver disease


[1] Recommendations for Routine Testing and Follow-up for Chronic Hepatitis B Virus (HBV) Infection
[2] CDC Recommendations for Hepatitis C Screening Among Adults — United States, 2020

Provide your feedback to OHA HERE

GOAL 3: ELIMINATE HEALTH DISPARITIES AND INEQUITIES

Recent trends in Oregon

  • Between 2016 and 2020, rates of cases of acute HBV were over 4 times higher in Native Hawaiian and Pacific Islanders than the state average.
  • 48% of cases of chronic HBV in Oregon between 2016-2020 occurred among people who are foreign-born.
  • Rates of chronic HBV are highest in Asians (nearly 19 times higher than state average), followed by Native Hawaiian and Pacific Islanders (15 times higher) and Black and African American people (5 times higher).
  • Both American Indian and Alaska Natives and Black people have higher rates of acute and chronic HCV compared to the state average.
  • Rates of deaths related to HCV are twice as high among Black people and American Indian/Alaska Natives than the state average.
  • Between 2016 and 2020, 26% of cases of acute HBV reported recent injection drug use, while 62% of those with HCV reported injection drug use.
  • In 2019-2020, 28% of Oregonians with acute HBV and 40% with acute HCV were houseless.

Rationale for Proposed Objectives and Strategies

  •  Viral hepatitis disproportionately impacts specific groups of people, many of whom experience discrimination and stigma.
  • Elimination of viral hepatitis requires engagement with communities experiencing health disparities.
  • Community-lead groups are more likely to be culturally competent and provide accurate information and services in native languages.
  • Healthcare care systems and healthcare professionals must provide culturally competent education, counseling, and care to individuals at risk of or infected with chronic viral hepatitis.
Goals 3. Eliminate health disparities and inequities
Objectives 3.1 Reduce stigma and discrimination in healthcare settings faced by people with or at increased risk for viral hepatitis 3.2 Reduce disparities in diagnosis of viral hepatitis, knowledge of status, engagement with care, and community stigma around diagnosis
Secondary Objectives 3.1.1 Address stigma, unconscious bias and discriminatory practices at health care delivery sites 3.2.1 Strengthen and build partnerships with organizations serving communities at risk for viral hepatitis
3.1.2 Expand culturally competent and linguistically appropriate care, treatment, and prevention services 3.2.2 Engage community leaders and people with lived experience to dispel viral hepatitis–related stigma

Objective 3.1 Eliminate disparities faced by people with and at risk for viral hepatitis in healthcare settings

Strategies

3.1.1 Address stigma, unconscious bias, and discriminatory practices at health care delivery sites

  • Increase culturally competent care navigation services and care management in primary care and emergency department settings
  • Promote recruitment of culturally and linguistically diverse community health workers (CHWs) to provide care navigation
  • Provide trainings on implicit bias and microaggression for clinic staff
  • Foster collaboration between healthcare systems and community-based organizations that serve priority populations to implement effective strategies for improving viral hepatitis care and treatment

3.1.2 Expand culturally competent and linguistically appropriate care, treatment, and prevention services

  • Promote recruitment of linguistically and culturally diverse staff in healthcare and MOUD/SUD treatment sites
  • Ensure that hepatitis and substance use recovery materials are available and translated into languages representing the populations utilizing clinic services
  • Using tools such as videos, infographics, audio materials for radio or podcasts, and social media messaging, develop culturally and linguistically responsive educational materials tailored to communities with a high prevalence of viral hepatitis, HIV and STIs,
  • Ensure interpreter service is available at healthcare and MOUD/SUD treatment facilities care

Objective 3.2 Reduce disparities in diagnosis of viral hepatitis, knowledge of status, engagement with care, and community stigma around diagnosis

Strategies

3.2.1 Strengthen and build partnerships with organizations serving communities at risk for viral hepatitis

  • Foster partnerships with organizations that serve disproportionately impacted populations, including community organizations, provider organizations, academic institutions, and offices of minority health, to raise awareness of viral hepatitis
  • Promote hepatitis prevention education, hepatitis treatment, and MOUD/SUD treatment for individuals in carceral settings

3.2.2 Engage community leaders and people with lived experience to dispel viral hepatitis–related stigma

  • Employ peer educators to raise awareness about HCV prevention and the availability of a cure in their respective communities
  • Share facts, recommendations, and personal stories in community settings and in the media to reach all people, especially those in disproportionately impacted communities
  • Increase social media campaigns highlighting treatment for HCV and lived experience of living with chronic hepatitis

Provide your feedback to OHA HERE

GOAL 4: IMPROVE SURVEILLANCE AND DATA USAGE

Rationale for Proposed Objectives and Strategies

Routine surveillance data from case investigations of cases of viral hepatitis are useful for monitoring trends in transmission of viral hepatitis and help local and state public health agencies develop better prevention and control strategies.

Data from hospitals, the Oregon State Cancer Registry (OSCaR), and death certificates can provide important information about complications of liver disease in hospitalized patients, cases of liver cancer, and deaths associated with chronic viral hepatitis.

Insurance claims data can be used to track how many Oregonians are getting tested and treated for chronic viral hepatitis.

These data help public health, health systems and community partners reach persons at risk for viral hepatitis, overcome the barriers of stigma and discrimination, provide testing and treatment, and monitor long-term complications of viral hepatitis.

Sharing data annually will allow Oregon to track our efforts towards elimination of chronic viral hepatitis in Oregon.

Goals 4. Improve surveillance and data usage
Objectives 4.1 Monitor and control spread of viral hepatitis 4.2 Monitor racial and ethnic disparities 4.3 Monitor morbidity and mortality due to viral hepatitis and track access to testing and treatment

Secondary Objectives

 

4.1.1 Investigate and implement control measures for acute cases of HAV, HBV, HCV and chronic cases of HBV 4.2.1 Improve collection of data on gender, race, ethnicity, language and disability 4.3.1 Monitor rates of hospitalizations, cases of liver cancer, and deaths related to viral hepatiti
4.1.2 Identify and respond to clusters of chronic HCV 4.2.2 Launch public dashboard with rates of viral hepatitis by age, gender, race, ethnicity, language, disability, and county 4.3.2 Track numbers of individuals with chronic HCV who receive confirmatory testing and initiate treatment

Objective 4.1 Monitor and control spread of viral hepatitis

Strategies

4.1.1 Investigate and implement control measures for acute cases of HAV, HBV, HCV and chronic cases of HBV

  • Conduct timely and complete investigation of cases and outbreaks of acute viral hepatitis

4.1.2 Identify and respond to clusters of chronic HCV

  • Develop protocols and identify resources to assist with responding to clusters of chronic HCV

Objective 4.2 Monitor racial and ethnic disparities

Strategies

4.2.1 Improve collection of data on gender, race, ethnicity, language and disability

  • Train LPHA and OHA staff in use of new standards and instruments for collecting data on race, ethnicity, language and disability (REALD) and sexual orientation and gender identity (SOGI)
  • Phase in Oregon administrative rules (OARs) requiring providers to collect and report REALD and SOGI data

4.2.2 Launch public dashboard with rates of viral hepatitis by age, sex, race, ethnicity, and county

  • Create OHA data mart to mine REALD/SOGI data from health systems data
  • Display racial, ethnic, and disability-related disparities when available

Objective 4.3 Measure morbidity and mortality due to viral hepatitis and track access to testing and treatment

Strategies

4.3.1 Monitor rates of hospitalizations, cases of liver cancer, and deaths related to viral hepatitis

  • Post annual burden of disease reports on OHA website
  • Update Oregon Viral Hepatitis Report every 3-5 years
  • Monitor racial, ethnic and disability-related disparities

4.3.2 Track numbers of individuals with chronic HCV who receive confirmatory testing and initiate treatment

  • Pilot reporting of negative HCV RNA results to estimate number of individuals receiving confirmatory testing and treatment
  • Analyze data from All Payer All Claims (APAC) reporting system to estimate numbers of Oregonians tested for HBV and HCV and treated for HCV annually
  • Post cascade of care data annually on OHA website

Provide your feedback to OHA HERE