Cherokee Nation Sets Blueprint for Elimination of Hepatitis C

Eliminating hepatitis C virus (HCV) is an achievable goal based on findings among the Cherokee Nation American Indian population.

Thus far, approximately half of its tribal citizens have been screened for HCV and approximately one-quarter who were estimated to be infected have already been cured. The findings were presented at the World Indigenous People’s Conference on Viral Hepatitis in Anchorage, Alaska.

“Various factors have combined to make elimination of hepatitis C possible,” said Dr Jorge Mera, head of infectious diseases at Cherokee Nation. “The development of new directly acting antiviral drugs (DAAs) has made hepatitis C treatment much more successful and with fewer side effects.

“Alongside this, in 2015 the US Centers for Disease Control and Prevention offered their support telling us they wanted us to aim for elimination. In collaboration with the University of Oklahoma, the Oklahoma State Health Department, and the CDC, we started our HCV elimination program in August 2015. This was possible through Gilead, one of the leading manufacturers of DAAs, who also donated $1.5 million through its Gilead Foundation to help with screening kits and research.”

Globally, there are more than 350,000 Cherokee Nation tribal citizens, with approximately 130,000 residing in northeastern Oklahoma.

Baby boomers—–born between 1945 and 1965––are 5 times more likely to have HCV than any other adults. Despite this, Dr Mera and his team are screening all individuals aged 20 to 69 years within the tribe’s boundary rather than just the baby-boomer generation, totaling some 80,000 individuals, according to a press release.

“Because Cherokee Nation citizens, under a treaty right with the United States Government have access to medical care, tracking them and screening them is slightly easier than might be so for other US populations,” Dr Mera noted.

The Indian Health Service (IHS) provides direct medical and public health services to members of Native American Tribes and Alaska Native people, including the Cherokee Nation. It is a division of the US Department of Health and Human Services that helps to fund care costs, as well as the W.W. Hastings Hospital—the one central hospital operated by the Cherokee Nation—and 8 rural health care centers across the tribe’s jurisdiction.

To provide these centers with the necessary support and training to screen and treat HCV, they implemented the program Extended Community Health Outcomes (ECHO) to train each health center using teleconference. Additionally, ECHO allows the health centers to connect with Dr Mera and other team members on a regular basis to present their cases.

“Anyone entering our health centers who is in this screening age range is offered a test, and almost everyone will say yes,” Dr Mera said. “For the 10% or so that say no, we will continue to offer screening whenever they next visit. However, not everyone is coming to the doctor, of course. So we had the idea of also screening in our dental clinics, to catch our patients in all areas of health care that they might be accessing. Patients who agree to be tested will receive the results then and there and those who test positive will be referred to the hepatitis C clinical provider on the same day in most cases.”

For mothers who are unsure of when they were infected with HCV, tests are automatically offered to any of their children who may have been infected during the pregnancy.

In the urgent care and emergency department space, patients who are seeking care and sign an informed consent will be tested for HCV unless they opt out. An estimated 70% of new diagnoses are from screenings in emergency care.

Prior research estimates the prevalence of HCV in Cherokee Nation is as high as 6%; however, newer findings indicate the prevalence is closer to 3.4%. Meaning, 2800 citizens of 80,000 screened would be expected to test positive for HCV; however, only 70% of cases would be expected to have chronic infection, with the remaining 30% self-clearing their infection.

Investigators estimate between 1800 and 2000 Cherokee Nation citizens will have chronic HCV.

In the 2 years since the program launched, approximately 46,000 individuals have been screened with 1076 testing positive. Of the patients who tested positive, 760 were chronically infected and required treatment, 605 had begun treatment—–with the other 155 awaiting tests or to start treatment––with 400 cured. Interestingly, the number of patients cured are thought to be higher because some patients do not return to receive a test to confirm they are cured.

“Through Cherokee Nation’s successful partnership with the CDC and the state of Oklahoma, and dedicated work by our epidemiologist and health employees, it has drastically cut hepatitis C rates in our tribal population,” said Chief Bill John Baker, Cherokee Nation principal. “We hope this blueprint of proactive screening and treatment can be replicated by other tribal health care systems nationwide, and even globally. Hepatitis C does not have to be the death sentence for Indigenous populations that it has historically been.”

Although the barriers to screening and testing for HCV are a work in progress in the Cherokee Nation, education and awareness remains a challenge, according to the release.

“We are trying to raise awareness among our citizens to prevent further cases,” Dr Mera said. “New treatments have few or no side effects and treatment is completed in just 12 weeks in most cases.”

In addition to “the ongoing dangers of injecting drug use, another problem we may have is that much of the tattooing in Cherokee Nation does not always take place in state-licensed facilities, and it could be a contributor,” Dr Mera noted.

Dr Mera hopes to also build on the elimination project to reach individuals who are harder to target, according to the release.

“We will apply for further agency grant funding to help train community health workers to test people who may never visit the doctor or dentist and educate our tribal citizens about why this elimination project is essential,” Dr Mera said. “This is similar to the way Navajo Nation American Indian tribe trained their community health workers to test and deliver care for HIV in their population.”

An estimated 71 million individuals worldwide are believed to be infected with HCV. Of whom, at least 3 million of those individuals are in the United States.

“This is an inspirational initiative by a population that has been deeply impacted by hepatitis C,” said Raquel Peck, chief executive of the World Hepatitis Alliance, London. “Cherokee Nation is showing that with political will, financial support, and engagement of the community, it is possible for them, and indeed other populations worldwide, to eliminate hepatitis C as a public health threat.”