Hepatitis C Epidemiologic Profile for Northern KentuckyHepatitis C Epidemiologic Profile for Northern Kentucky 2017 Page 7 1. Introduction About the virus Acute hepatitis C virus infection

Hepatitis CEpidemiologic Profilefor Northern Kentucky

2011-2015

Key Findings

In 2015*, Northern Kentucky’s acute hepatitis C rate of 9.5 cases per 100,000 population was more than 3.5 times the state rate (2.7) and more than 11 times the U.S. rate (0.8).

Cases of chronic hepatitis C are increasing.

Between 2011 and 2015, Kentucky had 2,180 hospitalizations for hepatitis C and related conditions.

Acute hepatitis C 2011-2015

The virus impacts more men and younger adults.

Voluntary case reporting in Northern Kentucky shows a rate of 286.6 per 100,000 population in 2015, nearly a three-fold increase since 2011.

(State and national data for chronic hepatitis C is not available.)

* The most recent year for which state and national data is available.

Note: Individuals may report zero or more risk factors.

• 24 Northern Kentucky residents treated forliver cancer at Kentucky hospitals were alsodiagnosed with hepatitis C.

• Liver transplants doubled in 2015 in Kentuckyand Northern Kentucky.

• 117 Northern Kentuckians had hepatitis Clisted as an underlying or contributing causeof death between 2011 and 2015.

• Of that total, Northern Kentucky incurred$4.2 million in hospital charges.

• Much of the cost burden is borne byMedicare and Kentucky’s Medicaid program,which are funded in part by tax dollars.

• More men are infected by nearlya 2:1 ratio.

• Men are infected at a rate of 12.5cases per 100,000 population.

• Women are infected at a rate of6.5 cases per 100,000 population.

• Largest percentage of casesin people ages 25-34.

2.70.8U.S. KY

9.5NKY

Leading Risk Factors

Hospitalizations in Kentuckycreated an economic burden exceeding $72 million overa five-year period.

INJECTION: 40.6%

NEEDLE SHARING: 24.9%

STREET DRUG USE,BUT NO INJECTION: 34.9%

Hepatitis C Epidemiologic Profile for Northern Kentucky 2017 Page 3

Project Team Authors Northern Kentucky Health Department Joyce Rice, RN, MSPH, Epidemiology Manager (previous) Debbie Young, MHI, Public Health Informatics Manager

Project Team Northern Kentucky Health Department Lynne M. Saddler, MD, MPH, District Director of Health Stephanie Vogel, M.Ed., MCHES, Director of Population Health Louise Kent, MBA, ASQ CQIA, Planning Administrator Ned Kalapasev, GIS Manager Zachary Raney, MPH, CHES, Epidemiology Manager MaAdwoa Asamoah, MPH, Epidemiologist Chip Lehman, MS, Epidemiologist

Kentucky Department for Public Health Kathy Sanders, RN, MSN, Kentucky Adult Viral Hepatitis Prevention and Control Program Coordinator Robert Brawley, MD, Chief of Infectious Disease Branch

Contributors Kentucky Department for Public Health Allison M. Lile, Health Care Data Administrator, Office of Health Policy Claudia Valdivieso, MPH, MS, Epidemiologist, Office of Vital Statistics Sara Robeson, Senior Epidemiologist, Division of Epidemiology and Health Planning

Special thanks to This project was funded through the Association of State and Territorial Health Officials (ASTHO) grant “Building State/Territorial Health Department Capacity to Develop and Utilize Viral Hepatitis Epidemiologic Profiles” through the Kentucky Department for Public Health, Division of Epidemiology and Health Planning, Infectious Disease Branch.

Stakeholders for providing feedback and direction for data used in creating this report.

Taffiny Paul and Stephanie Haggard, Division Secretaries, Northern Kentucky Health Department, for assistance with data clean-up and follow-up with stakeholders and organization.

Suggested citation Hepatitis C Epidemiologic Profile for Northern Kentucky (2017). Northern Kentucky Health Department.

Available online at https://nkyhealth.org/community-partner/health-data-plans-and-reports/health-reports/


Table of Contents

Key Findings .................................................................................................................................2

Project Team ................................................................................................................................3

Table of Contents .........................................................................................................................4

1. Introduction ...............................................................................................................................7

About the virus ..........................................................................................................................7

Transmission .............................................................................................................................7

Prevalence ................................................................................................................................7

Economic burden ......................................................................................................................8

References (Introduction) ..........................................................................................................8

2. Demographics of Northern Kentucky ........................................................................................9

Population density ................................................................................................................... 10

Population growth ................................................................................................................... 11

Age .......................................................................................................................................... 12

Race/ethnicity.......................................................................................................................... 13

References (Demographics) ................................................................................................... 13

3. Risk Factors ............................................................................................................................ 14

Injection drug use .................................................................................................................... 14

Mother-to-infant transmission .................................................................................................. 14

References (Risk Factors) ...................................................................................................... 15

4. Acute Hepatitis C .................................................................................................................... 16

Rates by gender ...................................................................................................................... 17

Rates by age ........................................................................................................................... 18

Risk factors ............................................................................................................................. 19

Rates by area development district ......................................................................................... 20

References (Acute Hepatitis C) ............................................................................................... 22

5. Chronic Hepatitis C ................................................................................................................. 23

Prevalence .............................................................................................................................. 23

Total by year ........................................................................................................................... 26

Total by gender ....................................................................................................................... 27

Total by age ............................................................................................................................ 28

References (Chronic hepatitis C) ............................................................................................ 28


6. Hospitalizations....................................................................................................................... 29

Kentucky hospitalizations by gender ....................................................................................... 29

Kentucky hospitalizations by age ............................................................................................ 29

Northern Kentucky hospitalizations by gender ........................................................................ 31

Northern Kentucky hospitalizations by age ............................................................................. 31

Economic burden (Primary hepatitis C diagnosis)................................................................... 32

Economic burden (Any HCV diagnosis) .................................................................................. 33

References (Hospitalizations): ................................................................................................ 36

7. Hepatocellular Carcinoma (Liver Cancer) ............................................................................... 37

Incidence ................................................................................................................................. 37

Hospitalizations ....................................................................................................................... 38

Mortality .................................................................................................................................. 39

References (Liver Cancer) ...................................................................................................... 40

8. Liver Transplants .................................................................................................................... 41

References (Liver Transplant): ................................................................................................ 42

9. Contribution of Hepatitis C to Liver Cancer and Transplants .................................................. 43

References (Contribution of Hepatitis C to Liver Cancer and Liver Transplants) .................... 46

10. Deaths Related to Hepatitis C............................................................................................... 47

Total by year (Hepatitis C – Underlying cause of death) ......................................................... 47

Total by year (Hepatitis C – Contributing cause of death) ....................................................... 49

Deaths by gender .................................................................................................................... 50

Total by age ............................................................................................................................ 50

Total by race ........................................................................................................................... 51

References (Deaths) ............................................................................................................... 51

11. Treatment ............................................................................................................................. 52

References (Treatment): ......................................................................................................... 53

12. Conclusion/Next Steps ......................................................................................................... 54

Appendix 1: Case Definitions and Selection Criteria................................................................... 55

Source: Centers for Disease Control and Prevention and Council for State and Territorial Epidemiologists ....................................................................................................................... 55

Selection Criteria: (for Kentucky Inpatient Hospital Discharge Claims data): .......................... 56

References (Appendix A) ........................................................................................................ 56

Appendix 2: Data Tables ............................................................................................................ 57

Appendix 3: Utilization Plan Logic Model and Description of Stakeholder Engagement ............. 76


Forward This epidemiologic profile was funded by a grant from the Association of State and Territorial Health Officials (ASTHO) awarded to the Kentucky Department for Public Health. NKY Health developed this report based on data for Kentucky, as well as the eight-county Northern Kentucky Area Development District. This report is designed to be used as a template for a statewide profile of hepatitis C in Kentucky, as well for profiles of the virus in the other area development districts in Kentucky. A description of how stakeholders were engaged to assure that this report met the requirements of its intended audience can be found in Appendix 3.


1. Introduction About the virus Acute hepatitis C virus infection is a short-term illness that occurs after someone is exposed to the hepatitis C virus. It usually occurs within the first six months after someone is exposed to the HCV.1 For most people, acute infection leads to chronic infection.

Chronic hepatitis C virus infection, a long-term illness that occurs when the hepatitis C virus remains in a person’s body, can last a lifetime and lead to serious liver problems, including cirrhosis (scarring of the liver) or liver cancer.1 Chronic hepatitis C is sometimes referred to as past or present hepatitis C, but will be referred to as chronic hepatitis C in this report.

Since the hepatitis C virus infects the liver, resulting symptoms can range from extreme fatigue, jaundice and joint paint to no symptoms at all. Because the infection is often asymptomatic, many people do not know that they are infected and do not seek medical care. In 75% to 85% of untreated cases of acute HCV infection, the infection will become chronic. Without treatment, 60% to 70% of those with chronic HCV infection will progress to chronic liver disease. If not treated, 5% to 20% of cases of chronic liver disease will progress to cirrhosis; and in 1% to 5% of cases of chronic HCV infection, HCV will lead to death.1

Transmission The hepatitis C virus is transmitted from person-to-person when blood from an infected person comes into contact with the blood of an uninfected person. Although sharing needles or drug paraphernalia is the primary method of transmission, HCV can also be spread, to a lesser extent, by sharing personal items such as razors or toothbrushes; having unprotected sex with an infected partner; or by obtaining a tattoo from an unlicensed person. There is also a 6% chance that the virus can be transmitted to a baby born to a hepatitis C positive mother.1 Prior to 1992, HCV was spread through blood transfusions and organ transplants; however, in 1992 blood banks began testing the blood supply.2

Prevalence United States It is estimated that there are currently 4.6 million people in the U.S. who are positive for the HCV antibody, indicating chronic infection. Of those, 3.5 million still have the virus in their system, meaning they are infectious. Nationally, the number of acute cases reported to the CDC increased more than 2.5 times between 2010 and 2014. This nationwide increase was due in part to enhanced surveillance in some states funded by the CDC.

In 2014, a total of 40 states reported 2,194 cases of acute hepatitis C, which represents a case rate of 0.7 cases per 100,000 population3. After adjusting for under diagnosis and underreporting, the CDC estimated that the number of new cases was actually over 30,000.3


Those affected were predominately young, white, had a history of injection drug use, previous use of an opioid, and lived in small rural towns, with a higher incidence seen in the Appalachian region of the U.S.3

Kentucky Kentucky had the highest reported case rates of acute hepatitis C in the nation between 2010 and 2014. Further, incidence of HCV in Kentucky increased more than 1.6 times between 2010 and 2014.

Economic burden Hospitalizations indicating HCV as the primary diagnosis are a good indicator of the economic burden experienced from hepatitis C. In the U.S. from 2010-2011, a total of 64,867 hospitalizations resulted in a total cost of $3.5 billion.

Findings from this report suggest that hepatitis C is growing in recent years and that hepatitis C is becoming a significant public health problem.4 Between 2011 and 2015, Kentucky had 2,180 hospitalizations for HCV and related conditions, with charges exceeding $72 million. The state averaged more than 400 hospitalizations per year with an average cost of $14.5 million per year.

References (Introduction) (1) Viral Hepatitis. (2017, January 27). Retrieved September 2016 from

https://www.cdc.gov/hepatitis/hcv/hcvfaq.htm.

(2) Zibbell, J. E., Iqbal, K., Patel, R. C., Suryaprasad, A., Sanders, K., & Moore-Moravian, L.

(2015, May 08). Increases in Hepatitis C Virus Infection Related to Injection Drug Use

Among Persons Aged ≤30 Years — Kentucky, Tennessee, Virginia, and West Virginia,

2006–2012. Retrieved June 2016 from

https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6417a2.htm?s_cid=mm6417a2_w.

(3) Viral Hepatitis. (2017, May 11). Retrieved June 2017 from

https://www.cdc.gov/hepatitis/statistics/index.htm.

(4) Xu, F., Tong, X., & Leidner, A. J. (2014). Hospitalizations And Costs Associated With

Hepatitis C And Advanced Liver Disease Continue To Increase. Health Affairs, 33(10),

1728-1735. doi:10.1377/hlthaff.2014.0096

https://www.cdc.gov/hepatitis/hcv/hcvfaq.htm

https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6417a2.htm?s_cid=mm6417a2_w

https://www.cdc.gov/hepatitis/statistics/index.htm


2. Demographics of Northern Kentucky For the purposes of this report, the Northern Kentucky region is comprised of eight counties,: Boone, Campbell, Carroll, Gallatin, Grant, Kenton, Owen and Pendleton.

In 2015, 454,020 people resided in Northern Kentucky. The region is served by two district health departments:

Northern Kentucky Health Department serving the residents of Boone, Campbell, Grant and Kenton Counties.

Three Rivers District Health Department serving the residents of Carroll, Gallatin, Owen and Pendleton Counties.

Figure 3.1 NKY Counties/Health Departments


Population density Northern Kentucky has a mix of urban, suburban and rural populations. The map below demonstrates population density; a measure of population per square mile.

Figure 3.2 NKY Population Density1


Population growth Overall population growth in Northern Kentucky for the time period of 2010-2015 is 3.5%. The map below demonstrates the variations in growth throughout Northern Kentucky, with the largest growth in Boone County (7.5%) and the largest population loss in Pendleton County (-3.2%).

Figure 3.3 NKY Population Change1


Age Age categories used in this report are shown in figure 3.4 below. The median age for Northern Kentucky between 2011 and 2015 ranges from 36.2 in more densely populated counties to 41.7 in the more rural areas2. The graph also displays the percentages for each age category for 2010 for Northern Kentucky, Kentucky and the U.S., indicating similar population distributions.

Women of childbearing age For the purpose of this report, women of childbearing age are defined as 15 to 44 years of age. In Northern Kentucky, 39% of women are of childbearing age.

0.0%

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Figure 3.4. Population by Age Group for US, KY and NKY1

2010 NKADD 2010 KY 2010 US 2010 NKY


Race/ethnicity The Northern Kentucky region is predominately (90.1%) white (non-Hispanic), 3.4% African American, 3.2% Hispanic, 1.4% Asian and 1.9% Other3-1. There is very little racial/ethnic diversity in Northern Kentucky, making racial and ethnic differences in populations difficult to determine based on small sample sizes. The area also has ties to Appalachia: Approximately 20% of Northern Kentucky respondents to the Kentucky Health Issues Poll reported being of Appalachian heritage.3 This estimate is determined via place-based status (respondent and/or parent was born in an Appalachian county).

Throughout this report, racial and ethnic diversity is reported where sufficient data allow for stable calculations.

References (Demographics) (1) Kentucky State Data Center. (n.d.). Retrieved April 2017 from http://ksdc.louisville.edu.

(2) Data Access and Dissemination Systems (DADS). (2010, October 05). American

FactFinder. Retrieved April 2017 from https://factfinder.census.gov.

(3) Kentucky Health Issues Poll. (2016). Retrieved from October 2017 from

http://www.oasisdataarchive.org/

Figure 3.5. Population by Race and Ethnicity in NKY1

White (90.1%)

Black (3.4%)

Asian (1.4%)

Other (1.9%)

Hispanic (3.2)

*Racial categories are non-Hispanic

http://ksdc.louisville.edu/

https://factfinder.census.gov/

http://www.oasisdataarchive.org/


3. Risk Factors The CDC states that the following are at a higher risk for HCV infection1:

Current or former injection drug users (see below)

Children born to HCV-positive mothers (see below)

Persons living with HIV infection

Persons exposed to HCV, such as health care workers after needle sticks involving HCV-positive blood, or recipients of blood or organs from a donor who tested HCV-positive

Recipients of clotting factor concentrates made before 1987

Recipients of blood transfusions or solid organ transplants before July 1992

Chronic hemodialysis patients

Injection drug use Northern Kentucky is in the midst of an opioid epidemic. Injection use of heroin, fentanyl and other opioids has resulted in an increase in the number of overdoses and overdose deaths in the area. The CDC states that, “Injection drug use is a well-known route of transmission of blood borne infections, particularly HIV, hepatitis B and hepatitis C.”2

In addition to the increase in overdoses and overdose deaths, this opioid epidemic has also resulted in increasing rates of hepatitis C transmitted by injection drug use and the sharing of needles. Risk factors identified in acute HCV cases in Northern Kentucky indicate that injection drug use (40.6%) and needle sharing (24.9%) were among the top risk factors in those responding to the CDC viral hepatitis case report (Figure 5.5)5.

In 2012 through 2014, the Kentucky Department for Public Health released funding for hepatitis C testing to local health departments to increase HCV testing initiatives. The Northern Kentucky Health Department participated in this pilot and tested 2,024 individuals for HCV. Of the 338 who tested positive for HCV, a total of 273 (80.8%) indicated a history of injection drug use. (Note: A large percentage of those tested were from local substance use disorder treatment centers, so this percentage does not reflect the region as a whole.)

Mother-to-infant transmission Infants are at risk of contracting HCV from their hepatitis C positive mother at birth. According to the CDC, there is a 6% chance that a baby born to a hepatitis C positive mother will also be infected.1 The higher the mother’s viral load, the higher the chance that the baby will be infected. Interventions such as Cesarean sections have not been shown to decrease the risk of transmission to the baby.3 These facts raise concerns about the number of women of childbearing age that are HCV positive and untreated.

In 2013 in Kentucky, reporting of women who were HCV positive and pregnant (perinatal HCV) was voluntary. In 2015, perinatal HCV reporting became mandatory. Ribonucleic acid testing provides accurate infant HCV results; however, testing antibodies prior to 18 months is inaccurate1. Thus, there is an 18-month lag in Kentucky data for mother-to-infant transmission rates.


Between the years of 2011 and 2015, a total of 73% of women who were diagnosed with HCV infections were between 15 and 44 years old, considered to be of childbearing age. As figure 4.1 (below) shows, cases increased almost 2.5 times between 2011 and 2015.

References (Risk Factors) (1) Viral Hepatitis. (2017, January 27). Retrieved September 2016 from


(2) Persons Who Use Drugs (PWUD). (2017, September 21). Retrieved April 2016 from

http://www.cdc.gov/pwud/.

(5) Koneru, A., Nelson, N., Hariri, S., Canary, L., Sanders, K. J., Maxwell, J. F., . . . Vellozzi,

C. (2016). Increased Hepatitis C Virus (HCV) Detection in Women of Childbearing Age

and Potential Risk for Vertical Transmission—United States and Kentucky, 2011-2014.

MMWR. Morbidity and Mortality Weekly Report, 65(28), 705-710.

doi:10.15585/mmwr.mm6528a2.

(6) Northern Kentucky Health Department data.

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Figure 4.1. Cases of Chronic Hepatitis C Among Females of Childbearing Age in NKY, 2011-20154


http://www.cdc.gov/pwud/


4. Acute Hepatitis C “New hepatitis C virus infections are increasing most rapidly among young people, with the highest overall number of new infections among 20 to 29-year-olds. This is primarily a result of increasing injection drug use associated with America’s growing opioid epidemic.1”

In Kentucky, acute hepatitis C is a reportable disease.

Confirmed cases of acute HCV infections peaked in 2013 in Northern Kentucky and began to decrease in 2014 and 2015. This is very similar to the trend of HCV in Kentucky (figure 5.1). Nationally, however, HCV case numbers increased from 2010 through 2013, decreased in 2014 and increased in 2015.2

10.4

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Figure 5.1. Rates of Acute Hepatitis C by Year in U.S., KY and NKY, 2011-20152,3,4

NKY

KY

US

2015: Kentucky acute hepatitis C case rates are more than 3 times U.S. case rates. Northern Kentucky acute hepatitis C case rates are more than 3.5 times Kentucky case rates and more than 11 times U.S. case rates.


Rates by gender Between 2011and 2015, Northern Kentucky’s overall HCV case rate was higher for males (13.3 per 100,000 population) than females (10.6 per 100,000 population) with 2013 being the exception. Kentucky case rates are consistently higher for males than females during this time period as well. U.S. case rates for males and females are very close, although the rate for males is slightly more than females. Figure 5.3 depicts the differences in case rates between the U.S., Kentucky and Northern Kentucky by gender.

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Figure 5.2. Acute Hepatitis C rates by Gender in U.S., KY and NKY, 2011-20152,3,4

NKY Male Rate KY Male Rate US Male Rate

NKY Female Rate KY Female Rate US Female Rate


Rates by age Figure 5.3 depicts acute HCV rates for 2011 - 2015 by age groupings. Individuals between the ages of 15 and 54 account for 98% of acute HCV infections; 42% of those individuals are between the ages of 25 and 34. This trend is mirrored at the state level with 97% of cases being in individuals between ages 15 and 54, and 44% between the ages of 25 and 34.

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Figure 5.3. Acute hepatitis C rates by Age Group in KY and NKY, 2011-20153,4

KY

NKY


Risk factors In Northern Kentucky, all potential acute hepatitis C cases are contacted by public health workers—a total of 249 potential cases between 2011 and 2015. These individuals were asked a series of questions from the CDC Viral Hepatitis Case Report related to behavior and risk factors within the time period of two weeks to six months prior to the onset of HCV symptoms.

While multiple attempts were made to contact an individual, more than one-quarter (27.7%) could not be contacted or declined to answer the questions. Additionally, 4% reported no risk factors. Individuals may indicate multiple risk factors, with the top risk factors being: injection drug use (40.6%); street drug use, but no injection (34.9%); sharing of needles/equipment (24.9%); hospital or dental surgery (17.7%); incarceration/jail (16.5%); and tattoo (13.7%). Of those receiving a tattoo within two weeks to six months of symptom onset, only 19.4% were obtained commercially at a licensed tattoo studio; the remaining were obtained in a correctional facility (8.3%) or other location (69.4%).

Note: Percentages in figure 5.4 add to more than 100% due to reporting of multiple risk factors.

40.6% 34.9%

24.9%

17.7% 16.5% 13.7%

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27.7%

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Figure 5.4. Reported Risk Factors Among Individuals with Acute Hepatitis C in NKY, 2011-20154

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Other Commercial Correctional

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Tatoo Source

Figure 5.5. Reported Locations Where Individuals with Acute Hepatitis C Received

Tattoos in NKY, 2012-20154

Survey results are self-reported and figures may be underreported for two reasons:

The subject matter is sensitive (and

in some cases refers to illegal

activity) and many decline to

respond.

This report utilized self-reported

figures only. For instance, if hospital

records indicate drug usage, but an

individual self-reports no drug

usage, then no drug usage was

recorded.


Rates by area development district The Commonwealth of Kentucky is segmented into 15 area development districts. The Northern Kentucky Area Development District includes Boone, Campbell, Carroll, Gallatin, Grant, Kenton, Owen and Pendleton Counties; and is the subject of this report.

Acute HCV case rates were calculated for each of the area development districts in Kentucky. Figure 5.6 shows statewide hepatitis C case rates versus rates in the three area development districts (Northern Kentucky, Big Sandy, Bluegrass) that had enough cases (>=5) to report per year. Similar to Kentucky, Big Sandy and Northern Kentucky case rates peaked in 2013 and declined in 2014 and 2015. (The remaining 12 area development districts had cases too small to report for at least one of the years 2011 through 2015).

Figure 5.7 depicts the case rates for acute HCV for each area development district. The rate was calculated using cumulated cases and population figures for 2011-2015 (a five-year average), since the individual cases were too small to report yearly for most of the area development districts. It is interesting to note that area development districts in northern and eastern sections of Kentucky have the highest case rates. Six area development districts have five-year averages greater than the five-year average for Kentucky (3.8 per 100,000 population) and include: Northern Kentucky (12), Big Sandy (10), Gateway (9.1), Cumberland Valley (6.9), Buffalo Trace (6.8) and FIVCO (6.7).

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Figure 5.6 Acute hepatitis C Case Rates:

Area Development Districts compared to Kentucky2

(Cases >=5 for all years)

KY Big Sandy Bluegrass Northern Kentucky


Figure 5.7 Acute Hepatitis C rates for Kentucky

by Area Development Districts, 2011-20153

Acute Hepatitis C Rates per 100,000, 2011-20152


References (Acute Hepatitis C) (1) Deadly virus concentrated among baby boomers and increasing rapidly among

new generations of Americans. (2017, May 11). Retrieved June 2017 from

https://www.cdc.gov/nchhstp/newsroom/2017/Hepatitis-Surveillance-Press-

Release.html.

(2) Viral Hepatitis. (2017, May 11). Retrieved June 2017 from


(3) Kentucky Department for Public Health data.


https://www.cdc.gov/nchhstp/newsroom/2017/Hepatitis-Surveillance-Press-Release.html




5. Chronic Hepatitis C Although chronic cases of HCV are not reportable in Kentucky, the Northern Kentucky Health Department began tracking them in 2000 for Northern Kentucky Health Department counties in its district (Boone, Campbell, Grant and Kenton), and in 2009 for those counties served by the Three Rivers District Health Department (Carroll, Gallatin, Owen and Pendleton). Originally, the purpose of tracking chronic hepatitis C was to avoid duplication of reporting of cases of acute HCV. However, as HCV increased at alarming rates in Northern Kentucky, tracking both acute and chronic cases has become a priority. Figures reported in this section may be lower than actual numbers due to the fact that:

Patients with chronic hepatitis C are asymptomatic; thus testing may not be ordered

Reporting of non-acute HCV is voluntary

Prevalence The number of cases and case rates for reported chronic hepatitis C have steadily increased during 2011-2015; in fact, cases and rates have nearly doubled from a rate of 150.8 per 100,000 is 2011 to 286.6 per 100,000 in 2015. Cases reported are more male (53%) than female (47%). More than half (55%) of the reported cases are individuals between the ages of 25 and 44; with the highest percentage (35%) being ages 25-34 years of age.

By ZIP code Yearly rates of reported cases of chronic hepatitis C were mapped by year for 2011-2015 (view all maps online). Maps for 2011 and 2015 are shown below. In 2011, the highest rates of chronic hepatitis C existed in small pockets of northern Kenton and Campbell Counties. By 2015, although the highest rates still existed in northern Kenton and Campbell Counties, high rates were also detected in Grant and Pendleton Counties.

https://nkhd.maps.arcgis.com/apps/TimeAware/index.html?appid=c2c4a55d7e9b437ba1230c90d0a6c64f


Figure 6.1. chronic Hepatitis C Rates by ZIP code in NKY for

20112

Figure 6.2 NKY Past and Present HCV2

Figure 6.2. Chronic Hepatitis C Rates by ZIP code in NKY for

20152

The maps at left and below) depict chronic hepatitis C for 2011 and 2015. The maps were produced utilizing ZIP code level data and show geographic prevalence of hepatitis C rates (per 100,000) by resident ZIP code in 2011 and 2015. The maps clearly indicate a progression of hepatitis C prevalence in most areas of Northern Kentucky. By 2015, most Zip Code rates exceeded 62.8. View yearly maps

https://nkhd.maps.arcgis.com/apps/TimeAware/index.html?appid=c2c4a55d7e9b437ba1230c90d0a6c64f


By county In 2015, the highest rates of chronic hepatitis C were in Grant, Pendleton, Kenton and Campbell Counties. Figure 6.7 below depicts the change in chronic hepatitis C rates from 2011 to 2015. As is evident below, increases between 2011 and 2015 vary widely across the counties, with Grant County increasing by more than 200% and Carroll County increasing by 30%.

Considerations: Case rates for counties with smaller populations are more sensitive to variability. Therefore, conclusions drawn from these comparisons should be carefully examined.

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Figure 6.7. Chronic Hepatitis C Rates by county in NKY 2011 compared to 20152

2011 2015


Total by year Reported cases of chronic hepatitis C nearly doubled between 2011 and 2015. During this timeframe, the case rate in Northern Kentucky increased 90% from 150.8 in 2011 to 286.6 in 2015.

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250.0

300.0

350.0

0

200

400

600

800

1000

1200

1400

2011 2012 2013 2014 2015

Cas

e R

ate

s (p

er

10

0,0

00

) Cas

es

Figure 6.3 NKY Chronic Hepatitis C2

Cases and Case Rates 2011-2015

Cases Case Rate


Total by gender Since 2011, chronic cases of hepatitis C are composed of slightly more males than females. Cases were 54% male and 46% female in 2011 and in 2015. Cases and case rates for males, as well as females, nearly doubled between 2011 and 2015.

359

457 515

596

697

16

3.7

20

7.3

23

2.3

26

6.6

31

0.0

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300

400

500

600

700

800

2011 2012 2013 2014 2015

Cas

e R

ate

(p

er

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00

)

Cas

es


Male Cases and Case Rates

Male Cases Male Rates

299

413

522 501

597

13

3.6

18

3.8

23

0.7

21

9.7

26

0.5

0.0

50.0

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150.0

200.0

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0

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400

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2011 2012 2013 2014 2015

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e R

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)

Cas

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Female Cases and Rates

Female Cases Female Rates


Total by age From 2011 to 2015, the most dramatic increase was reported for individuals between the ages of 25 and 44. Within that age range, rates for individuals between ages 25-34 increased from 260.1 to 730.2 cases per 100,000 population; and rates for individuals ages 35-44 increased from 159.5 to 466.9 cases per 100,000 population. Both age categories increased nearly three-fold between 2011 and 2015.

References (Chronic hepatitis C) (1) Viral Hepatitis. (2017, May 11). Retrieved June 2017 from

https://www.cdc.gov/hepatitis/statistics/index.htm.


21

1.7

26

0.1

15

9.5

23

7.2

18

7.1

80

.1

29

3.5

73

0.2

46

6.9

30

9.6

25

2.1

94

.4

0.0

200.0

400.0

600.0

800.0

15-24 25-34 35-44 45-54 55-64 65-74

Rat

e p

er

10

0,0

00

Age

Figure 6.6. NKY chronic Hepatitis C rates by Age 2

2011 compared to 2015

2011 2015



6. Hospitalizations The Kentucky Cabinet for Health and Family Services, Office of Health Policy queried Kentucky inpatient hospital discharge claims and provided hepatitis C-related claim data for the years 2011-20151. (Specific selection criteria can be found in Appendix I).

Results for both HCV-related hospitalizations were analyzed by primary diagnosis versus any diagnosis (included in the patient record, but not primary reason for hospitalization). Results for both of these data sets will be presented in the following section.

Considerations This data is for Kentucky residents treated in Kentucky hospitals only; therefore, hospitalizations in other states for Kentucky residents are not included. This is particularly important in Northern Kentucky, since Northern Kentucky residents are often hospitalized in Cincinnati facilities. Therefore, the hospitalization data for Northern Kentucky is likely under-reported.

Hospitalizations associated with hepatitis C are expensive. The total health care cost for hepatitis C (liver disease) in the U.S. in 2011 was $6.5 billion, with costs projected to peak in 2024 at $9.1 billion.2 This section covers the economic burden of hepatitis C hospitalizations for 2011-2015 for Kentucky as well as Northern Kentucky.

Kentucky hospitalizations by gender Hospitalizations in Kentucky for primary or any diagnosis of hepatitis C are more likely among males than females. Primary diagnoses are more frequently male (63% male/37% female) as opposed to any diagnosis which is more evenly distributed (56% male/44% female).

Kentucky hospitalizations by age When analyzing the following figures (7.1 and 7.2), it is clear that hospitalizations are higher for those age 45-64 regardless of primary/any diagnosis. It is important to note that percentages of males exceed females in all categories for primary diagnosis; however, females exceed male percents in age 15-34 for any hepatitis C diagnosis. It is possible that this is due to the females being of childbearing age, but additional analysis and data is needed to confirm this assumption.


4%

13% 13%

30% 32%

6% 1%

0%

5%

10%

15%

20%

25%

30%

35%

% o

f IP

Ho

spit

aliz

atio

ns

Age Category

Figure 7.1. Age Distribution of Inpatient Hospitalizations in Kentucky with Hepatitis C as a Primary Diagnosis, 2011-20151

Male Female KY

7%

20

%

18

%

27

%

22

%

4%

1%

0%

5%

10%

15%

20%

25%

30%

% o

f H

osp

ital

izat

ion

s

Age Category

Figure 7.2. Age Distribution of Inpatient Hospitalizations in Kentucky with Hepatitis C as any Diagnosis, 2011-20151

Male Female KY


Northern Kentucky hospitalizations by gender Similar to Kentucky, hospitalizations in Northern Kentucky for patients with a primary diagnosis of hepatitis C are more male (61%) than female (39%). The Northern Kentucky data also follows the Kentucky male/female trend for any HCV diagnosis (52% male/48% female) where males exceed females but to a lesser degree than primary diagnoses.

Northern Kentucky hospitalizations by age Looking at age categories in Northern Kentucky, percentages of males exceed females for patients with a primary diagnosis of hepatitis C in all categories except age 25-34. Similar to Kentucky, females with any diagnosis of hepatitis C have higher hospitalization rates than males in their childbearing years. This is concerning due to the fact that there is a 6% transmission rate of the virus from mother-to-child.3

8%

19% 18%

24% 27%

3% 0%

0%

5%

10%

15%

20%

25%

30%

% o

f IP

Ho

spit

aliz

atio

ns

Age Category

Figure 7.3. Age Distribution of Inpatient Hospitalizations in NKY with Hepatitis C as a Primary Diagnosis, 2011-20151

Male Female NKY


Economic burden (Primary hepatitis C diagnosis) In 2011-2015, Kentucky had 2,180 hospitalizations with a primary diagnosis of hepatitis C with charges exceeding $72 million; averaging over 400 hospitalizations per year and $14.5 million in charges per year. Northern Kentucky contributed to these figures with 207 of the hospitalizations and $4.2 million of the charges; averaging 41 hospitalizations per year and average annual charges exceeding $850,000.

Both the state and Northern Kentucky saw higher charges as age increased, with a peak at age 65-74 in Kentucky and age 55-64 in Northern Kentucky. Overall, Northern Kentucky average hospitalization charges are $10,000 -$15,000 lower per patient than Kentucky. In fact, when looking at all of the area development districts in Kentucky, Northern Kentucky’s average charges were the lowest in the state.

12

%

23

%

16

%

26

%

18

%

4%

1%

0%

5%

10%

15%

20%

25%

30%

% o

f IP

Ho

spit

aliz

atio

ns

Age Category

Figure 7.4 Age Distribution of Inpatient Hospitalizations in NKY with Hepatitis C as any Diagnosis, 2011-20151

Male Female NKY

Economic burden of primary HCV

diagnosis

Inpatient hospitalization charges in 2011-2015:

Kentucky: $72 million

Northern Kentucky: $4.2 million

Hospitalization charges increase with age.


Economic burden (Any HCV diagnosis) In 2011-2015, Kentucky had 43,465 hospitalizations with any hepatitis C diagnosis, with charges nearing $1.5 billion; averaging 8,693 hospitalizations per year and nearly $300 million per year. Northern Kentucky contributed to these figures with 5,299 of the hospitalizations and $125 million of the charges; averaging 1,060 hospitalizations per year and average annual charges exceeding $25 million.

Similar to primary hepatitis C diagnosis figures, both Kentucky and Northern Kentucky saw higher charges as age increased. This increase peaks at age 65-74 in Kentucky and age 55-64 in Northern Kentucky. Overall, Northern Kentucky’s average hospitalization charges are lower than Kentucky. Throughout this report, Northern Kentucky hospitalization case numbers and cost figures tend to be lower than other area development districts (Figure 7.7)

0

5000

10000

15000

20000

25000

30000

35000

40000

45000

M F 15 - 24 25 - 34 35 - 44 45 - 54 55 - 64 65 - 74 75-84

Ave

rage

Ch

arge

s Figure 7.5. Average Inpatient Hospitalization Charges for Patients with a

Primary Diagnosis of Hepatitis C in KY and NKY by Gender and Age Group, 2011-20151

KY NKADD KY Avg ($33,335) NKADD Avg ($20,690)

Economic burden of any HCV diagnosis

Average annual inpatient hospitalization charges:

Kentucky: $1.5 billion

Northern Kentucky: $125 million

Hospitalization charges increase with age.


0

5000

10000

15000

20000

25000

30000

35000

40000

45000

50000

Avg

Ch

arge

s

Figure 7.6. Average Inpatient Hospitalization Charges for Patients with Any Diagnosis of Hepatitis C in Kentucky and NKY by Age Group,

2011-20151

KY NKADD KY Avg ($34,110) NKADD Avg ($23,645)


Considerations

Hospitalization data contains records for Kentucky residents treated at Kentucky hospitals. It does not include any hospitalization data outside of Kentucky. Thus, with Northern Kentucky’s close proximity to Cincinnati’s hospital network, it is possible that rates/costs are lower due to the fact that Northern Kentucky residents may frequent Cincinnati hospitals for hepatitis C care.

$35,556

$32,511

$20,690

$48,905

$31,851

$33,935

$37,716

$28,877

$25,238

$38,442

$26,526

$29,162

$37,237

$33,829

$31,587

$32,171

$33,885

$23,645

$39,090

$37,972

$29,822

$42,036

$31,617

$35,546

$27,759

$27,382

$36,301

$37,012

$42,066

$36,445

PURCHASE

PENNYRILE

NORTHERN KY

LINCOLN TRAIL

LAKE CUMBERLAND

KY RIVER

KIPDA

GREEN RIVER

GATEWAY

FIVCO

CUMBERLAND VALLEY

BUFFALO TRACE

BLUEGRASS

BIG SANDY

BARREN RIVER

Figure 7.7. Average Inpatient Hospitalization Charges for Patients with Any Diagnosis of Hepatitis C in Kentucky by Area Development District

2011-20151

Any HCV Diagnosis Primary HCV Diagnosis

NKY is lowest


References (Hospitalizations): (1) Kentucky Cabinet for Health and Family Services, Office of Health Policy (2017,

April 29.) Kentucky Inpatient Hospital Discharge Claim Data 2011-2015.

Unpublished data. (See Appendix 1: Selection Criteria)

(7) Razavi, H., Elkhoury, A. C., Elbasha, E., Estes, C., Pasini, K., Poynard, T., &

Kumar, R. (2013). Chronic hepatitis C virus (HCV) disease burden and cost in

the United States. Hepatology, 57(6), 2164-2170. doi:10.1002/hep.26218

(8) Viral Hepatitis. (2017, January 27). Retrieved September 2016 from




7. Hepatocellular Carcinoma (Liver Cancer) Incidence Hepatitis C, left untreated, often progresses to chronic liver disease, including liver cancer. Liver and intrahepatic bile duct cancer incidence was queried from the Kentucky Cancer Registry for the years 2010-2014. (2015 was not yet published at the time of this report.) Five-year rates for each of the Kentucky area development districts are mapped below. The statewide incidence rate for 2010-2014 is 9.2 per 100,000 population. Area development districts in the two lighter shades are below the Kentucky average, where area development districts presented in shades of darker orange and red indicate rates higher than Kentucky average.

Figure 8.1. Incident Rates for Liver Cancer for Kentucky by Area Development District (ADD), 2010-

20141


Hospitalizations In Kentucky, there were 1,227 hospitalizations for hepatocellular carcinoma (liver cancer) during 2011-2015. Of those, 63% were male and 37% were female. The CDC’s Annual Report to the Nation on the Status of Cancer, 1975-2012 indicates that the rate of deaths due to liver cancer is increasing faster than for any other type of cancer3. The CDC cites that hepatitis C is a contributing factor in 50% of liver cancers.

Hospitalizations in Kentucky for liver cancer indicate that 18% had a hepatitis C diagnosis. The number of hospitalizations for liver cancer (between 226 and 251 cases) remained stable during 2011-2015. Of those, 75% were between the ages of 45-74; with the most liver cancer hospitalizations being ages 55-64 (33%). Almost half (48%) of liver cancer hospitalizations were patients covered by Medicare, with 28% commercial insurance and 18% Medicaid.

In Northern Kentucky, there were 78 liver cancer hospitalizations during 2011-2015. Of those, 68% were male and 32% were female. A larger percentage of liver cancer hospitalizations in Northern Kentucky (31%) had a hepatitis C diagnosis (Figure 10.1), than comparable data for Kentucky (18%). All hospitalizations in Northern Kentucky were individuals ages 45 or older, with 85% being aged 45-74. Similar to Kentucky, the largest group of hospitalizations was for patients aged 55-64; and almost half (49%) of liver cancer hospitalizations are patients covered by Medicare.

Note: The data presented here does not indicate primary site of cancer; since Kentucky has high rates of lung and colon cancer, it is possible that the reported cases of liver cancer are due to metasteses from other sites.

5 12 9 12 35

214

400

311

172

57

0

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100

150

200

250

300

350

400

450

<1 1-14 15-24 25 - 34 35 - 44 45 - 54 55 - 64 65 - 74 75 - 84 85+

# H

osp

ital

izat

ion

s

Age Category

Figure 8.2. Number of Liver Cancer Hospitalizations by Age Group for Liver Cancer in Kentucky, 2011-20152


Mortality Liver and intrahepatic bile duct cancer mortality was queried from the Kentucky Cancer Registry for the years 2010-2014. (2015 data was not yet published at the time of this report.) Five-year rates for each of the area development districts are mapped below. The Kentucky mortality rate for 2010-2014 is 7.1 per 100,000 population. Area development districts in the two lighter shades are below the Kentucky average, where area development districts presented in shades of darker orange and red indicate rates higher than the Kentucky average.

Figure 8.3. Mortality Rates of Liver Cancer in Kentucky by Area Development District (ADD), 2010-

20141


References (Liver Cancer) (1) Kentucky Caner Registry. (n.d.). Cancer Incidence and Mortality Rates by Area

Development District in Kentucky (2010-2014). Retrieved from March 2017 from

http://cancer-rates.info/ky/index.php

(2) Kentucky Cabinet for Health and Family Services, Office of Health Policy (2017,



(3) Centers for Disease Control and Prevention. (n.d.). Viral Hepatitis and Liver

Cancer. Retrieved March 2017 from

https://www.cdc.gov/nchhstp/newsroom/docs/factsheets/viral-hep-liver-

cancer.pdf.

http://cancer-rates.info/ky/index.php

https://www.cdc.gov/nchhstp/newsroom/docs/factsheets/viral-hep-liver-cancer.pdf

https://www.cdc.gov/nchhstp/newsroom/docs/factsheets/viral-hep-liver-cancer.pdf


8. Liver Transplants Liver transplants may occur in response to liver damage including cirrhosis and liver failure. In Kentucky, there were 359 liver transplants during 2011-2015. Of those, 66% were male and 34% were female. The CDC notes that chronic hepatitis C infection is the leading indication for liver transplants in the U.S.2

In Kentucky, only 75 (21%) of the liver transplants had a HCV diagnosis. The number of liver transplants in Kentucky doubled in 2015 from previous years: of the 359 liver transplants over the five year period, 35% (125) were in 2015. A total of 79% of liver transplant recipients were between the ages of 45-74, with the most liver transplant recipients being ages 55-64. Third-party payer types for liver transplants are closely dispersed, with 37% commercial insurance payers, 25% Medicaid and 35% Medicare. No significant trends in payers exist over the years.

In Northern Kentucky, there were 23 liver transplants during 2011-2015 that were performed in Kentucky hospitals. Of those 57% were male and 43% were female. Only 17% had a hepatitis C diagnosis. Similar to the state data for all of Kentucky, liver transplants doubled in 2015 from previous years. Although there are not enough cases in Northern Kentucky to provide stable age calculations, it appears as though liver transplant recipients are somewhat younger (peak age 45-54) than the average for Kentucky. Note: The low numbers of Northern Kentucky hospitalizations may be due to residents seeking hepatitis C treatment and liver transplants in Cincinnati hospitals.

9 5 12

36

92

142

0

20

40

60

80

100

120

140

160

<1 15 - 24 25 - 34 35 - 44 45 - 54 55 - 64

# Tr

ansp

lan

ts

Age Category

Figure 9.1. Number of Liver Transplants by Age for Kentucky Residents that were Performed in Kentucky, 2011

Liver transplant hospitalizations in Kentucky doubled in 2015

from the years prior since 2011.


References (Liver Transplant): (1) Kentucky Cabinet for Health and Family Services, Office of Health Policy (2017,



(2) Viral Hepatitis. (2017, January 27). Retrieved June 2017 from


59 48

66 61

125

0

50

100

150

2011 2012 2013 2014 2015

# Tr

ansp

lan

t H

osp

Figure 9.2. Number of Liver Transplants by

Year for Kentucky Residents that were performed in Kentucky, 2011-20151



9. Contribution of Hepatitis C to Liver Cancer

and Transplants Hepatitis C is a known contributing factor to both liver cancer and transplants. Since the rates of acute hepatitis C are higher than U.S. averages in Kentucky and particularly in Northern Kentucky, it is very important to understand the contribution of hepatitis C to long-term health outcomes, specifically liver cancer and transplants. Figure 10.1 below displays the percentage of liver cancer and transplant hospitalizations where hepatitis C has been diagnosed.

Considerations Figures are calculated from inpatient hospitalization data and does not include outpatient treatment data for liver cancer. Hospitalization data contains records for Kentucky residents treated at Kentucky hospitals. It does not include any hospitalization data outside of Kentucky. Thus, with Northern Kentucky’s close proximity to Cincinnati’s hospital network, it is possible that rates are lower due to the fact that Northern Kentucky residents may frequent Cincinnati hospitals for hepatitis C care.

It is also important to look at charges and payer sources for the later stage disease outcomes. Figure 10.2 indicates that Medicare pays for more of the liver cancer charges, whereas figure 10.3 shows that commercial insurance pays for higher percentages of liver transplants. As figures 10.4 and 10.5 demonstrate, average charges associated with liver transplant hospitalizations tend to be almost 10 times the average charges for hospitalizations associated with liver cancer.

With a cure for hepatitis C available, yet very expensive, it is important to evaluate the cost of initial treatment versus the economic burden of the long-term effects of Kentuckians living with hepatitis C.

With the availability of a cure for hepatitis C,

it is important to evaluate the cost of treatment versus the economic burden of

long-term health outcomes.


18% 21%

31%

17%

0%

5%

10%

15%

20%

25%

30%

35%

Liver Cancer (Hep C +) Liver Transplant (Hep C +)

% H

ep

C P

osi

tive

Figure 10.1. Liver Cancer and Liver Tranplant Inpatient Hospitalizations in KY and NKY that have Hepatitis C

Diagnosis, 2011-20151

KY NKY

28%

18%

48%

18% 22%

49%

0%

20%

40%

60%

Commercial Medicaid Medicare

Figure 10.2 Liver Cancer Payer Percentages1

KY vs NKY (2011-2015)

KY (LC) NKY (LC)

39% 28% 32%

48%

22% 30%

0%

20%

40%

60%


Figure 10.3 Liver Transplant Payer Percentages1

KY vs NKY (2011-2015)

KY (LT) NKY (LT)


53

,54

1

62

,51

7

47

,42

8

69

,25

9

37

,99

5

26

,85

8

-

10,000

20,000

30,000

40,000

50,000

60,000

70,000

80,000


Ave

rage

Ch

arge

s

Figure 10.4. Average Charges for Liver Cancer Inpatient Hospitalizations by Payer for KY and NKY, 2011-20151

KY (LC) NKY (LC)

43

2,6

08

51

2,1

56

43

4,5

16

38

1,7

52

69

9,7

06

36

1,8

84

-

100,000

200,000

300,000

400,000

500,000

600,000

700,000

800,000


Ave

rage

Ch

arge

s

Figure 10.5. Average Charges for Liver Transplant Inpatient Hospitalizations by Payer for KY and NKY, 2011-20151

KY (LT) NKY (LT)


References (Contribution of Hepatitis C to Liver Cancer and

Liver Transplants) 1. Kentucky Cabinet for Health and Family Services, Office of Health Policy

(2017, April 29.) Kentucky Inpatient Hospital Discharge Claim Data 2011-

2015. Unpublished data. (See Appendix 1: Selection Criteria)


10. Deaths Related to Hepatitis C The hepatitis C virus kills more Americans than any other infectious disease reported to the CDC. Data released in May 2017 indicate that nearly 20,000 Americans died from hepatitis C-related causes in 2015, and the majority of deaths were people aged 55 and older.1

The figures shown in this section were produced by queries run against death records for the years 2011-2015 obtained from the Office of Vital Statistics within the Kentucky Department for Public Health. The queries include figures for deaths categorized with hepatitis C as the underlying (primary) cause of death or one of the contributing causes of death listed on the death certificates. The terms underlying and contributing are utilized in mortality statistics for consistency with the National Center for Health Statistics coding instructions.

Considerations Death certificates in Kentucky allow for specification of an underlying of death and up to 20 contributing causes.

Deaths in this section are presented as rates to allow for comparison across differing populations.

Total by year (Hepatitis C – Underlying cause of death) Approximately one-third (34%) of the 46 hepatitis C-related deaths in Northern Kentucky indicate hepatitis C as the underlying cause of death. More often than not, hepatitis C is listed as one of the contributing causes of death. Figure 9.1 below shows the death rate for Northern Kentucky for the years 2011 – 2015 for deaths with hepatitis C as the underlying cause of death. The number of deaths with hepatitis C as the underlying cause of death is low (a total of 46 over five years); therefore, discretion should be used when analyzing the data.


1.8

2.2

1.6

1.6

1.8

0.0

0.5

1.0

1.5

2.0

2.5

2011 2012 2013 2014 2015

De

ath

s p

er

10

0,0

00

Figure 11.1. Mortality Rate for NKY with Hepatitis C as Underlying Cause of Death, 2011-20152

Mortality Rate

Average Rate (2011-2015)

Trend Line


Total by year (Hepatitis C – Contributing cause of death) This section outlines deaths where hepatitis C is listed in the underlying cause or any other contributing cause of death. Figure 11.2 indicates an increasing trend for death rates related to hepatitis C. Nationally, the death rate for deaths associated with HCV increased from 4.7 deaths per 100,000 population in 2010 to 5.0 deaths per 100,000 population in 20141; whereas, in the same time period, the Northern Kentucky HCV death rate increased from 4.3 to 7.3 per 100,000 population.

Figure 11.3 depicts the underlying cause for all hepatitis C-related deaths in Northern Kentucky. Chronic hepatitis C is reported as the underlying cause in 34% of the deaths, followed by liver cell carcinoma (15%) and alcoholic cirrhosis (15%). Six percent (6%) of the deaths were attributed to liver, unspecified. The “Other” category (30%) covers a wide-array of causes of death, but none emerged large enough to report.

4.3

4.9

4.5

5.1

7.3

0.0

1.0

2.0

3.0

4.0

5.0

6.0

7.0

8.0

2011 2012 2013 2014 2015

Rat

e p

er

10

0,0

00

Figure 11.2. Mortality Rate for NKY for Hepatitis C-related Deaths, 2011-20152

Mortality rate

5-yr average

Trend Line

34%

15% 6%

15%

30%

Figure 11.3. Causes of Death for Individuals with Hepatitis C listed as a Underlying or Contributing Cause of Death on Death Certificate 2011-20152

Chronic viral hepatitis C

Liver cell carcinoma

Liver, unspecified

Alcoholic cirrhosis of liver

Other


Deaths by gender Between 2011 – 2015, there were more almost twice as many deaths related to hepatitis C for males (69.2%) than females (30.8%). Figure 11.4 below shows the death rate for males in Northern Kentucky. Nationally, in 2014, hepatitis C-related deaths were 2.6 times more common in males than in females.3

Total by age Hepatitis C-related deaths in Northern Kentucky are much higher for those between the ages of 45 and 64. Figure 11.5 below depicts death rates for selected age categories to demonstrate the high death rate in the 45-54 and 55-64 age categories. (Note: Age categories not shown did not contain enough deaths to calculate a reliable death rate). In 2014, the highest mortality rates due to HCV in the nation were seen in the 55 to 65 year old age groups. Northern Kentucky follows this national trend. This is the major reason the CDC has called for all individuals in the Baby Boomer generation, those born between 1945 and 1965, to be tested for HCV at least once.3

2011 2012 2013 2014 2015

Male 5.9 6.8 5.9 7.6 10.2

Female 2.7 3.1 3.1 2.6 4.4

-

5.0

10.0

15.0

Rat

e p

er

10

0,0

00

Figure 11.4 NKY Hepatitis C Deaths where Hepatitis C is listed as cause

of death 2

2.7

13.2

18.6

3.7 6.2

0.0

5.0

10.0

15.0

20.0

35-44 45-54 55-64 65-74 75-84

Rat

e p

er

10

0,0

00

Age Category

Figure 11.5 NKY hepatitis C-related deaths by Age where hepatitis C is

listed as cause of death.3


Total by race Northern Kentucky hepatitis C-related deaths for the time period of 2011 through 2015 were primarily non-Hispanic white (97.4%). There were too few deaths in other categories of race or ethnicity to report.

References (Deaths) 1. Deadly virus concentrated among baby boomers and increasing rapidly

among new generations of Americans. (2017, May 11). Retrieved June 2017

from https://www.cdc.gov/nchhstp/newsroom/2017/Hepatitis-Surveillance-

Press-Release.html

2. Kentucky Department for Public Health. Vital statistics death records.

Accessed March and April 2017.

3. Viral Hepatitis. (2016, September 22). Retrieved November 2016 from

https://www.cdc.gov/hepatitis/statistics/2014surveillance/index.htm



https://www.cdc.gov/hepatitis/statistics/2014surveillance/index.htm


11. Treatment In the past few years, medication regimens for active hepatitis C have evolved into oral medications taken over a 12-week time period. The treatment for hepatitis C is usually done on an outpatient basis. Physician visits and lab tests are required during the treatment to monitor RNA levels and to assess for side effects.

In an article published in the journal Liver International, McGowan and Fried note, “Despite the availability of highly effective therapy for hepatitis C virus (HCV) infection, few patients receive treatment. Barriers arising at multiple levels, from diagnosis to specialist referral, may impede the delivery of hepatitis C care. At the patient level, lack of awareness, fear of side effects, poor adherence, and co-morbid conditions may prevent treatment. For providers, limited knowledge, lack of availability, and communication difficulties may be problematic. At the government and payer level, a lack of promotion, surveillance and funding may interfere.”1 Further, since a significant number of HCV infections are often associated with injection drug use, additional misconceptions and barriers may prevent uptake of treatment. An August 2017 report by the National Alliance of State and Territorial AIDS Directors called Science over Stigma: The Public Health Case Against HCV Treatment Sobriety Restrictions describes some of the requirements that pose barriers to HCV treatment for the people most at risk.

The cost of treatment for HCV infections varies widely depending on the genotype of the virus, complications from the infection and previous treatment history. Genotype 1 is the most common genotype seen in the U. S. with 70 to 75% of cases. The cost of treating genotype 1 in a previously untreated patient, without cirrhosis, ranges from $55,000 to $150,000. For genotype 2 or genotype 3, the cost of treatment increases and can range between $75,000 to $294,0002.

Much of these costs are borne by state programs. In fiscal year 2015-2016, Kentucky’s Medicaid program spent $69.7 million on pharmacy claims to treat 833 beneficiaries, or $83,735 apiece, according to the Cabinet for Health and Family Services.3

With the high costs of treatment of HCV infection and its associated conditions, it is clear that in Kentucky and Northern Kentucky a public health approach is needed to continue to prevent new HCV infections, particularly associated with injection drug use, and to work with health care systems and payers to link people who are infected with early treatment to prevent the more expensive long-term complications of HCV infection. Early successful treatment decreases the risks of liver disease and premature death, reducing the costs to the health care system and payers.

Treatment Cost Scenario

In 2015, more than 1,300 Northern

Kentucky individuals were reported with

chronic HCV.

The cost of treating even half of these individuals at the

lowest treatment rate of $55,000 equates to an economic burden for

medication only exceeding $35.5

million.


References (Treatment): 1. Mcgowan, C. E., & Fried, M. W. (2011). Barriers to hepatitis C treatment.

Liver International, 32, 151-156. doi:10.1111/j.1478-3231.2011.02706.x

2. Hepatitis c online, treatment of HCV genotype 1, module 5, lesson 1. (n.d.).

Retrieved July 2017 from http://www.hepatitisc.uw.edu/

3. Estep, B. (2017, May 22). We have an epidemic. Kentucky now leads the

nation in hepatitis C infection. Lexington Herald Leader.

http://www.hepatitisc.uw.edu/


12. Conclusion/Next Steps Kentucky led the nation in acute hepatitis C rates from 2010-2014, and continues to exceed national rates. At a local level, Northern Kentucky leads the state in five-year rates of acute HCV. In addition, chronic hepatitis C rates in Northern Kentucky continue to increase.

This report outlines rates of acute and chronic hepatitis C in Kentucky and Northern Kentucky, as well as costs associated with hospitalizations, liver cancer and liver transplants. It is designed to assist stakeholders in the region as they collaborate in combating the high rates of hepatitis C in Northern Kentucky.

This report does have some limitations, including that it does not contain figures for outpatient treatment costs.

This disease is increasing in epidemic proportions, and expenses associated with treatment, as well as associated disease burden will also continue to increase. Public health efforts for reducing the economic burden of hepatitis C in Northern Kentucky are increasing awareness, diagnosis and prevention efforts, which include:

Implementation of additional Syringe Access Exchange Programs.

Additional efforts for HCV testing and diagnosis.

Increased public and professional awareness and education.

Increased education and prevention targeted to at-risk populations.

Increased access to treatment


Appendix 1: Case Definitions and Selection

Criteria Source: Centers for Disease Control and Prevention and

Council for State and Territorial Epidemiologists

Acute hepatitis C: An illness with discrete onset of any sign or symptom consistent with acute viral hepatitis, plus meeting required laboratory criteria. Laboratory criteria for diagnosis of acute HCV:

A positive test for antibodies to hepatitis C virus (anti-HCV)

Hepatitis C virus detection test:

Nucleic acid test for HCV RNA positive (including qualitative, quantitative or genotype testing) Required as of 2016

A positive test indicating presence of hepatitis C viral antigen(s) * * When and if a test for HCV antigen(s) is approved by FDA and available.1

Chronic hepatitis C: A long long-term illness that occurs when the hepatitis C virus remains in a person’s body. Hepatitis C virus infection can last a lifetime and lead to serious liver problems, including cirrhosis (scarring of the liver) or liver cancer.2

For diagnosis, the laboratory criteria require one or more of the following (CDC, 2016):

Anti-HCV positive (repeatedly reactive) by enzyme immunoassay (EIA).

Verified by at least one more specific assay, or HCV nucleic acid test (NAT) positive, or anti-HCV screening-test positive with an assay-specific signal-to-cutoff ratio predictive of a true case.

No clinical symptoms are required; however, the case must be known to not be acute.

Case determination process: In Kentucky, a positive HCV blood test is reported to the local health department. The health department investigates to determine whether the case meets the criteria to be classified as acute (new infection) or a chronic (past infection):

If the case was previously reported, then it is defined as chronic and not reported to the state. Since chronic hepatitis C is not required to be reported in many states, comparisons to state and U.S. data can only done for acute (new) HCV infections.

If the case is new, clinical criteria and multiple lab tests are reviewed to determine whether the case is acute and whether it should be reported to the state. The Kentucky Department for Public Health makes the final designation.


Selection Criteria: (for Kentucky Inpatient Hospital Discharge

Claims data):

Selection criteria for hospitalizations (Section 7) included:

Patients from Kentucky, including the Northern Kentucky region: o Discharge dates from Jan. 1, 2011, through Dec. 31, 2015 o Discharges and total charges by year, age group, race and ethnicity o Discharge data indicating HCV as primary diagnosis o Discharge data indicating HCV as any diagnosis o ICD9/10 codes queried for HCV included: 07041, 07044, 07051, 070, 54,

0707, 07070, 07071, B171, B1710, B1711, B182, B192, B1920, B1921 o Data queried on April 29, 2017

Selection criteria for liver cancer (Section 8 and 10) included:

Patients from Kentucky, including the Northern Kentucky region: o Discharge dates from Jan. 1, 2011, through Dec. 31, 2015 o Discharges and total charges by patient area development district, year,

age group, race, ethnicity, gender, hepatitis C status and payer o Procedure (any): ICD9/10 codes: 155, 1550, 1551, 1552, 1553, 1554,

1555, 1556, 1557, 1558, 1559, C22, C220, C221, C222, C223, C224, C225, C226, C227, C228, C229

o Data queried on May 2, 2017

Selection criteria for liver transplants (Section 9 and 10) included:

Patients from Kentucky, including the Northern Kentucky region: o Discharge dates from Jan. 1, 2011, through Dec. 31, 2015 o Discharges and total charges by patient area development district, year,

age group, race, ethnicity, gender, hepatitis C status and payer o Discharge data indicating liver transplant as primary diagnosis o Discharge data indicating liver transplant as any diagnosis o ICD9/10 codes queried for liver cancer included: 50.5, 50.51, 50.59,

0FY00Z0, 0FY00Z1, 0FY00Z3 o Data queried on May 2, 2017

References (Appendix A) (1) Hepatitis C, acute: 2016 case definition. (n.d.). Retrieved September 2017 from

https://wwwn.cdc.gov/nndss/conditions/hepatitis-c-acute/case-definition/2016

(2) Viral Hepatitis. (2017, January 27). Retrieved September 2016 from


https://wwwn.cdc.gov/nndss/conditions/hepatitis-c-acute/case-definition/2016

https://www.cdc.gov/hepatitis/hcv/hcvfaq.htm.%20Accessed%20Sept.%202016


Appendix 2: Data Tables

Section 3: Demographics of Northern Kentucky Area Development District

2011 2012 2013 2014 2015

Northern Kentucky 443,080 445,168 447,987 451,592 454,020 COUNTY: 2011 2012 2013 2014 2015 Boone 121,737 123,316 124,442 126,413 127,712 Campbell 90,940 90,908 90,988 91,833 92,066 Grant 24,816 24,485 24,753 24,875 24,757 Kenton 160,406 161,711 163,145 163,929 165,012 Northern Kentucky Health District

397,899 400,020 403,328 407,050 409,547

Carroll 11,013 10,900 10,953 10,815 10,699 Gallatin 8,612 8,479 8,474 8,589 8,636 Owen 10,858 10,765 10,662 10,645 10,730 Pendleton 14,698 14,604 14,570 14,493 14,408 Three Rivers Health District

45,181 44,748 44,659 44,542 44,473

GENDER 2011 2012 2013 2014 2015 Male 219,297 220,504 221,719 223,551 224,805 Female 223,783 224,664 226,268 228,041 229,215 AGE 2011 2012 2013 2014 2015 0-14 94,157 94,225 94,195 93,815 93,082 15-24 57,148 57,258 57,267 58,095 57,914 25-34 61,524 61,381 61,101 61,411 61,625 35-44 60,183 59,594 59,428 59,108 59,329 45-54 66,195 65,548 64,980 64,490 63,951 55-64 53,459 54,263 56,110 57,424 58,711 65-74 28,710 31,046 32,568 34,444 36,010 75-84 15,702 15,649 15,956 16,356 16,731 85+ 6,002 6,204 6,382 6,449 6,667 Data source: Kentucky State Data Center: http://ksdc.louisville.edu



Section 3: Demographics of Kentucky

2011 2012 2013 2014 2015

Kentucky 4,369,356 4,380,415 4,395,295 4,413,457 4,425,092 GENDER 2011 2012 2013 2014 2015 Male 2,149,874 2,157,711 2,163,396 2,173,158 2,179,094 Female 2,219,482 2,222,704 2,231,899 2,240,299 2,245,998 AGE 2011 2012 2013 2014 2015 0-14 849,107 849,272 844,643 841,958 838,887 15-24 591,188 592,853 596,295 600,871 596,559 25-34 569,158 567,662 564,035 565,862 568,388 35-44 570,028 566,136 564,798 561,197 559,036 45-54 637,556 627,061 619,528 610,933 603,912 55-64 560,468 562,778 571,744 578,122 585,545 65-74 334,546 355,298 370,128 385,387 398,866 75-84 185,832 186,384 189,439 193,232 196,538 85+ 71,473 72,971 74,685 75,895 77,361 Area Development Districts

Barren River 286,581 288,378 290,973 292,969 296,087 Big Sandy 154,310 153,156 151,591 149,979 147,841 Bluegrass 779,078 785,667 791,885 798,462 806,391 Buffalo Trace 56,628 56,447 56,204 55,968 55,753 Cumberland Valley 237,058 235,891 235,324 234,708 234,019 FIVCO 137,464 136,983 136,266 135,913 135,286 Gateway 82,194 82,423 83,248 83,505 84,214 Green River 214,565 215,169 215,371 215,457 216,435 Kentucky River 114,465 112,813 111,132 109,918 108,911 KIPDA 966,744 974,625 983,724 989,654 994,665 Lake Cumberland 208,442 208,431 208,532 208,326 208,287 Lincoln Trail 273,289 272,755 274,086 273,937 271,243 Northern Kentucky 442,561 444,050 446,833 449,939 452,623 Pennyrile 218,821 220,855 218,707 217,887 217,059 Purchase 197,154 197,156 196,601 196,435 195,797 Data source: Kentucky State Data Center: http://ksdc.louisville.edu



Section 5: Acute Hepatitis C in Northern Kentucky Area Development District Northern Kentucky 2011 2012 2013 2014 2015 2011-15 Cases 46 58 71 50 43 268 Case rate 10.4 13.0 15.8 11.1 9.5 12.0 GENDER 2011 2012 2013 2014 2015 2011-15 Male 27 31 34 28 28 148 Female 19 27 37 22 15 120 Case rate Male 12.3 14.1 15.3 12.5 12.5 13.3 Female 8.5 12.0 16.4 9.6 6.5 10.6 AGE 2011 2012 2013 2014 2015 2011-15 0-14 0 0 0 0 0 0 15-24 9 19 18 14 12 72 25-34 24 23 27 22 17 113 35-44 9 7 14 6 9 45 45-54 * 9 10 7 * 34 55-64 0 0 * * 0 * 65-74 0 0 0 0 * * 75-84 0 0 0 0 0 0 85+ 0 0 0 0 0 0 Case rate 2011 2012 2013 2014 2015 2011-15 0-14 0.0 0.0 0.0 0.0 0.0 0.0 15-24 15.7 33.2 31.4 24.1 20.7 25.0 25-34 39.0 37.5 44.2 35.8 27.6 36.8 35-44 15.0 11.7 23.6 10.2 15.2 15.1 45-54 * 13.7 15.4 10.9 * 10.5 55-64 0.0 0.0 * * 0.0 * 65-74 0.0 0.0 0.0 0.0 * * 75-84 0.0 0.0 0.0 0.0 0.0 0.0 85+ 0.0 0.0 0.0 0.0 0.0 0.0 Reporting 2011 2012 2013 2014 2015

Reported N/A N/A 71 56 46 % confirmed 98.6% 89.3% 91.3%

Data source: Local health department data, Kentucky Department for Public Health *Too few to report


Section 5: Acute Hepatitis C in Kentucky Kentucky 2011 2012 2013 2014 2015 2011-15 Cases 142 178 226 175 121 842 Case rate 3.2 4.1 5.1 4.0 2.7 3.8 GENDER 2011 2012 2013 2014 2015 2011-15 Male 70 97 119 95 67 448 Female 67 79 107 80 54 387 Unknown 5 * 0 0 0 7 Case rate Male 3.3 4.5 5.5 4.4 3.1 4.1 Female 3.0 3.6 4.8 3.6 2.4 3.5 AGE 2011 2012 2013 2014 2015 2011-15 0-14 0 0 * 0 0 * 15-24 29 40 46 42 32 189 25-34 62 77 93 80 49 361 35-44 30 34 49 31 27 171 45-54 13 24 30 17 11 95 55-64 6 * 6 * * 19 65-74 * 0 0 0 * * 75-84 0 0 0 0 0 0 85+ 0 0 0 0 0 0 Unknown 0 * 0 * 0 *

Case rate 2011 2012 2013 2014 2015 2011-15 0-14 0.0 0.0 * 0.0 0.0 * 15-24 4.9 6.7 7.7 7.0 5.4 6.3 25-34 10.4 13.6 16.5 14.1 8.6 12.6 35-44 5.8 6.0 8.7 5.5 4.8 6.2 45-54 2.0 3.8 4.8 2.8 1.8 3.1 55-64 1.1 * 1.0 * * 0.7 65-74 * 0.0 0.0 0.0 * * 75-84 0.0 0.5 0.0 0.5 0.0 0.2 85+ 0.0 0.0 0.2 0.0 0.0 0.0 Cases by area development district

2011 2012 2013 2014 2015 2011-15

Barren River 5 * 5 * 5 20 Big Sandy 13 15 24 18 6 76 Bluegrass 11 27 24 17 8 87 Buffalo Trace * * * * 5 19 Cumberland Valley 15 26 23 13 * 81 FIVCO 9 * 14 10 12 46 Gateway 8 * 12 8 7 38


Green River * 5 * * * 16 Kentucky River 11 * * 0 * 20 KIPDA * 20 15 34 14 86 Lake Cumberland * * 10 * * 21 Lincoln Trail * 8 8 8 * 31 Northern Kentucky 46 58 71 50 43 268 Pennyrile * * 5 0 * 11 Purchase 6 * 5 * * 22 Total Kentucky 142 178 226 175 121 842 Case rates by area development district

2011 2012 2013 2014 2015 2011-15

Barren River 1.7 * 1.7 * 1.7 1.4 Big Sandy 8.4 9.8 15.8 12.0 4.1 10.0 Bluegrass 1.4 3.4 3.0 2.1 1.0 2.2 Buffalo Trace * * * * 9.0 6.8 Cumberland Valley 6.3 11.0 9.8 5.5 * 6.9 FIVCO 6.5 * 10.3 7.4 8.9 6.7 Gateway 9.7 * 14.4 9.6 8.3 9.1 Green River * 2.3 * * * 1.5 Kentucky River 9.6 * * 0.0 * 3.6 KIPDA * 2.1 1.5 3.4 1.4 1.8 Lake Cumberland * * 4.8 * * 2.0 Lincoln Trail * 2.9 2.9 2.9 * 2.3 Northern Kentucky 10.4 13.1 15.9 11.1 9.5 12.0 Pennyrile * * 2.3 0.0 * 1.0 Purchase 3.0 * 2.5 * * 2.2 Total Kentucky 3.2 4.1 5.1 4.0 2.7 3.8 Data Source: Kentucky Department for Public Health *Too few to report


Section 6: Chronic Hepatitis C in Northern Kentucky Area Development District Northern Kentucky Area Development District 2011 2012 2013 2014 2015 Cases 668 884 1038 1098 1301 Case rate 150.8 198.6 231.7 243.1 286.6 GENDER 2011 2012 2013 2014 2015 Male 359 457 515 596 697 Female 299 413 522 501 597 Gender unknown 10 14 * * 7 Case rate: Male 163.7 207.3 232.3 266.6 310.0 Female 133.6 183.8 230.7 219.7 260.5 Age 2011 2012 2013 2014 2015 0-14 * 8 9 7 10 15-24 121 184 223 218 170 25-34 160 263 304 353 450 35-44 96 143 192 178 277 45-54 157 147 170 187 198 55-64 100 115 109 124 148 65-74 23 18 24 27 34 75-84 * * 6 * 7 85+ * * * 0 * Age unknown 0 0 0 * 5 Case rate 0-14 * 8.5 9.6 7.5 10.7 15-24 211.7 321.4 389.4 375.2 293.5 25-34 260.1 428.5 497.5 574.8 730.2 35-44 159.5 240.0 323.1 301.1 466.9 45-54 237.2 224.3 261.6 290.0 309.6 55-64 187.1 211.9 194.3 215.9 252.1 65-74 80.1 58.0 73.7 78.4 94.4 75-84 * * 37.6 * 41.8 85+ * * * 0.0 *

COUNTY 2011 2012 2013 2014 2015 Boone 119 185 189 198 245 Campbell 148 198 198 248 284 Grant 34 59 82 75 104 Kenton 310 365 464 453 555


Carroll 15 24 42 28 19 Gallatin 7 16 11 21 19 Owen 7 * 11 16 15 Pendleton 28 34 41 59 60 Case rate Boone 97.8 150.0 151.9 156.6 191.8 Campbell 162.7 217.8 217.6 270.1 308.5 Grant 137.0 241.0 331.3 301.5 420.1 Kenton 193.3 225.7 284.4 276.3 336.3 Carroll 136.2 220.2 383.5 258.9 177.6 Gallatin 81.3 188.7 129.8 244.5 220.0 Owen 64.5 * 103.2 150.3 139.8 Pendleton 190.5 232.8 281.4 407.1 416.4 Data source: Local health department data *Too few to report


Section7: Inpatient Hospitalizations – Hepatitis C Primary Diagnosis for Northern Kentucky Northern Kentucky 2011 2012 2013 2014 2015 2011-15 Cases 48 49 51 31 28 207 Total charges

909,827

1,105,886 995,741 520,058 751,258 4,282,771

Average charges 18,955 22,569 19,524 16,776 26,831 20,690 GENDER 2011 2012 2013 2014 2015 2011-15 Male 61%

Count 31 29 28 20 19 127 Total charges 552,618 511,378 549,495 356,268 254,386 2,224,145 Average charge 17,826 17,634 19,625 17,813 13,389 17,513 Female 39%

Count 17 20 23 11 9 80 Total charges 357,210 594,508 446,246 163,791 496,872 2,058,626 Average charges 21,012 29,725 19,402 14,890 55,208 25,733 AGE Total Male Female Average

charges (Total)

Average charges

(Male)

Average charge

(Female) 15-24 16 10 6 9,741 10,893 7,821 25-34 39 19 20 11,882 12,343 11,444 35-44 38 21 17 20,882 22,189 19.267 45-55 50 32 18 24,974 17,927 37,503 55-64 56 40 16 25,774 18,222 44,654 65-74 7 * * 20,456 * * 75-84 0 0 0 0 0 0 85+ * * * * * * Total

Data source: Kentucky Cabinet for Health and Family Services, Office of Health Policy *Too few to report


Section 7: Inpatient Hospitalizations – Hepatitis C Any Diagnosis for Northern Kentucky Northern Kentucky

2011 2012 2013 2014 2015 2011-15

Cases 664 844 1,189 1,157 1,445 5,299 Total charges

16,177,916 20,270,066 26,870,974 25,266,146 36,710,120 125,295,221

Average charges

24,364 24,017 22,600 21,838 25,405 23,645

GENDER 2011 2012 2013 2014 2015 2011-15 Male 52%

Count 367 438 636 578 743 2,762 Total charges

9,545,482 11,434,144 14,554,208 13,053,936 18,654,978 67,242,749

Average charges

26,009 26,105 22,884 22,585 25,108 24,346

Female 48%

Count 297 406 553 579 702 2,537 Total charges

6,632,433 8,835,922 12,316,765 12,212,211 18,055,142 12,316,765

Average charges

22,331 21,763 22,273 21,092 25,720 22,882

AGE Total Male Female Average

charges (Total)

Average charges

(Male)

Average charges (Female)

15-24 621 224 397 14,760 14,142 15,109 25-34 1,227 509 718 16,103 15,049 16,850 35-44 856 413 443 20,896 19,490 22,207 45-55 1,373 812 561 27,000 27,380 26,450 55-64 944 647 297 34,819 32,999 38,784 65-74 211 120 91 31,039 30,944 31,164 75-84 57 30 27 31,078 32,147 29,890 85+ 10 * * 22,371 * * Total 5,299 * * 23,645 24,346 22,882 Data source: Kentucky Cabinet for Health and Family Services, Office of Health Policy *Too few to report


Section 7: Inpatient Hospitalizations – Hepatitis C as Primary Diagnosis for Kentucky Kentucky 2011 2012 2013 2014 2015 2011-15

Cases 388 449 479 436 428 2180

Total charges 10,889,232 14,625,043 14,122,398 16,628,655 16,405,466

72,670,794

Average charges 28,065 32,572 29,483 38,139 38,331

33,335

GENDER 2011 2012 2013 2014 2015 2011-15

Male 63%

Count 231 305 309 279 242 1366

Total charges 7,017,893 9,938,985 9,001,605 11,301,050 7,883,647

45,143,179

Average charge 30,380 32,587 29,131 40,506 32,577

33,048

Female 37%

Count 157 144 170 157 186 814

Total charges 3,871,339 4,686,058 5,120,793 5,327,605 8,521,819

27,527,615

Average charges 24,658 32,542 30,122 33,934 45,816

33,818

AGE Total Male Female Average charges (Total)

Average charges

(Male)

Average charges

(Female)

1-4 * * * 7,046 7,046

0

4-14 0 0 0 0 0 0

15-24 89 39 50 14,055 11,923 15,718

25-34 283 154 129 18,406 20,916

15,410

35-44 283 156 127 27,419 32,734

20,891

45-55 660 450 210 36,629 33,856

42,571

55-64 704 481 223 40,231 38,887

43,129

65-74 127 74 53 41,740 29,453

58,895

75-84 31 10 21 19,497 21,777

18,411

85+ * * * * * *

Total 2180 1366 814 33,335 33,048

33,818

Area Development District Total Total charges

Average charges

Barren River 59

1,863,637 31,587

Big Sandy 139

4,702,177 33,829

Bluegrass 369 37,237


13,740,539

Buffalo Trace 17

495,755 29,162

Cumberland Valley 240

6,366,124 26,526

FIVCO 109

4,190,154 38,442

Gateway 39

984,274 25,238

Green River 47

1,357,235 28,877

KIPDA 453

17,085,254 37,716

Kentucky River 146

4,954,539 33,935

Lake Cumberland 107

3,408,018 31,851

Lincoln Trail 54

2,640,871 48,905

Northern Kentucky 207

4,282,771 20,690

Pennyrile 98

3,186,049 32,511

Purchase 96

3,413,397 35,556

Data Source: Kentucky Cabinet for Health and Family Services, Office of Health Policy

*Too few to report

Section 7: Inpatient Hospitalizations – Hepatitis C Any Diagnosis for Kentucky Kentucky 2011 2012 2013 2014 2015 2011-15

Cases 6,814 7,569 8,360 9,252 11,470 43,465

Total charges 205,899,506 254,516,057 269,770,936 315,877,763 436,515,756 1,482,580,017

Average charges 30,217 33,626 32,269 34,142 38,057 34,110

GENDER: 2011 2012 2013 2014 2015 2011-15

Male 56%

Count 3,897 4,232 4,738 5,163 6,225 24,255

Total charges 127,203,211 152,755,234 165,306,424 191,246,586 256,425,715 892,937,170

Average charges 32,641 36,095 34,889 37,042 41,193 36,815

Female 44%

Count 2,917 3,337 3,622 4,089 5,245 19,210

Total charges 78,696,295 101,760,823 104,464,512 124,631,177 180,090,041 589,642,848

Average charges 26,979 30,495 28,842 30,480 34,336 30,695

AGE Total Male Female Average $ Average $ Average $


(Total) (Male) (Female)

<1 9 * * 37,249 38,315 35,116

1-14 13 * * 38,728 8,674 47,744

15-24 3,008 881 2,127 20,564 25,730 18,424

25-34 8,794 3,739 5,055 23,413 25,762 21,675

35-44 7,810 4,374 3,436 31,282 32,187 30,131

45-55 11,823 7,502 4,321 36,672 37,321 35,545

55-64 9,565 6,368 3,197 44,708 45,355 45,355

65-74 1,836 1,117 719 46,691 47,633 47,633

75-84 519 229 290 38,198 41,863 41,863

85+ 88 36 52 33,253 36,399 36,399

Total 43,465 24,255 19,210 34,110 36,815 30,695

Area Development District Total

Total charges

Average charges

Barren River 1,008 36,736,912 36,445

Big Sandy 2,241 94,270,886 42,066

Bluegrass 7,258 268,630,483 37,012

Buffalo Trace 340 12,342,452 36,301

Cumberland Valley 5,529 151,397,705 27,382

FIVCO 2,036 56,516,505 27,759

Gateway 705 25,060,044 35,546

Green River 912 28,834,856 31,617

KIPDA 9,457 397,533,880 42,036

Kentucky River 4,343 129,515,427 29,822

Lake Cumberland 1,680 63,793,319 37,972

Lincoln Trail 823 32,171,041 39,090

Northern Kentucky 5,299 125,295,221 23,645

Pennyrile 863 29,243,164 33,885

Purchase 971 31,238,120 32,171

Data source: Kentucky Cabinet for Health and Family Services, Office of Health Policy

*Too few to report

Section 8: Liver Cancer for Northern Kentucky Northern Kentucky 2011 2012 2013 2014 2015 2011-15 Cases 13 18 15 15 17 78 Total Charges

384,166 580,512 710,504 676,447

549,739

2,901,368 Average Charges ($) 29,551 32,251 47,367 45,096 32,338 37,197 GENDER 2011 2012 2013 2014 2015 2011-15

Male 68%

Count 6 14 10 8 15 53 Total charges

55,742 453,547 514,547 217,896

444,051 1,785,783 Average charges 25,957 32,396 51,455 27,237 29,603 33,694 Female 32%


Count 7 * 5 7 * 25 Total charges 228,424 * 195,957 458,551 * 1,115,584 Average charges 32,632 * 39,191 65,507 * 44,623 AGE Count Percent <1 * * 1-14 * * 15-24 * * 25-34 * * 35-44 * * 45-55 18 23% 55-64 30 38% 65-74 18 23% 75-84 10 13% 85+ * *

HCV diagnosis Count Percent Yes 24 31% No 54 69%

Payer Commercial Medicaid Medicare Other Self

Pay Total

Counts 14 17 38 * 8 78

Percents 18% 22% 49% * 10% Total charges 969,627 645,917 1,020,610 * 226,852 2,901,368 Average charges 69,259 37,995 26,858 * 28,356 37,197 Data source: Kentucky Cabinet for Health and Family Services, Office of Health Policy *Too few to report


Section 8: Liver Cancer for Kentucky Kentucky 2011 2012 2013 2014 2015 2011-15 Cases 226 263 237 250 251 1,227 Total charges 10,101,355 13,676,208 13,896,469 12,597,317 13,906,813

64,178,162

Average charges 44,696 52,001 58,635 50,389 55,406 52,305 GENDER 2011 2012 2013 2014 2015 2011-15

Male 63%

Count 143 159 150 162 164 778 Total charges 6,543,811 8,643,368 8,792,016 8,079,863 8,101,765 40,160,822 Average charges 45,761 54,361 58,613 49,876 49,401

51,621

Female 37%

Cases 83 104 87 88 87 449 Total charges 3,557,544 5,032,841 5,104,453 4,517,454 5,805,048

24,017,340

Average charges 42,862 48,393 58,672 51,335 66,725 53,491 AGE Total Percent <1 5 0% 1-14 12 1% 15-24 9 1% 25-34 12 1% 35-44 35 3% 45-55 214 17% 55-64 400 33% 65-74 311 25% 75-84 172 14% 85+ 57 5% Total 1227 100%

HCV diagnosis

Total Percent

Yes 219 18% No 1008 82%

Payer Commercial Medicaid Medicare Other Self Pay Charity Cases 340 220 585 19 43 20 Percent 28% 18% 48% 2% 4% 2% Total $ 18,204,087 13,753,827 27,745,617 745,399 2,189,360


1,539,873 Average $ 53,541 62,517 47,428 39,232 50,915 76,994 Data source: Kentucky Cabinet for Health and Family Services, Office of Health Policy *Too few to report

Section 8: Liver Cancer Incidence and Mortality for Kentucky by Area Development District

Incidence (2010-2014) Mortality (2010-2014)

Area Development District

Population at Risk Cases

Crude Rate

Population at Risk Deaths Crude Rate

Barren River 1,443,374 118 8.2 1,443,374 109 7.5 Big Sandy 761,864 58 7.6 761,864 58 7.6 Bluegrass 3,926,344 313 8 3,926,344 221 5.6

Buffalo Trace 281,949 28 9.9 281,949 19 6.7 Cumberland Valley 1,178,996 101 8.6 1,178,996 89 7.5 FIVCO 684,406 64 9.3 684,406 49 7.2 Gateway 410,877 39 9.5 410,877 31 7.5 Green River 1,073,938 91 8.5 1,073,938 74 6.9 KIPDA 561,970 51 9.1 561,970 40 7.1 Kentucky River 4,875,186 572 11.7 4,875,186 417 8.6 Lake Cumberland 1,038,917 88 8.5 1,038,917 73 7 Lincoln Trail 1,364,692 119 8.7 1,364,692 94 6.9 Northern Kentucky 2,227,751 169 7.6 2,227,751 129 5.8 Pennyrile 1,095,635 109 9.9 1,095,635 82 7.5 Purchase 983,704 94 9.6 983,704 65 6.6 Kentucky 21,909,603 2,014 9.2 21,909,603 1,550 7.1 Data source: Kentucky Cancer Registry, 2010-2014 *Too few to report


Section 9: Liver Transplant Hospitalizations for Northern Kentucky Northern Kentucky

2011 2012 2013 2014 2015 2011-15

Cases 5 * * * 10 23 Total charges

3,307,074 * * * 5,158,19

6 10,230,989 Average charges

661,415

* *

*

515,820 444,826 GENDER 2011 2012 2013 2014 2015 2011-15 Male *too few to segment 43%

Cases * * * * * 10 Total charges * * * * * 3,145,607 Average charges * * * * * 314,561 Female 57%

Cases * * * * * 13 Total charges * * * * * 7,085,382 Average charges * * * * * 545,029 AGE *too few to segment HCV diagnosis: Yes 17% No 83%

Payer Commercial Medicaid Medicare

Cases 11 5 7

Percent 48% 22% 30%

Total $ 4,199,276 3,498,528 2,533,185

Average $ 381,752 699,706 361,884

Data source: Kentucky Cabinet for Health and Family Services, Office of Health Policy *Too few to report


Section 9: Liver Transplant Hospitalizations for Kentucky Kentucky 2011 2012 2013 2014 2015 2011-15 Cases 59 48 66 61 125 359 Total charges

24,658,624 15,051,435 23,722,781 23,724,013 76,055,104

163,211,956 Average charges 417,943 313,572 359,436 388,918 608,441

454,629

GENDER 2011 2012 2013 2014 2015 2011-15 Male 66% Cases 41 31 46 42 78 238 Total charges 16,323,682 8,796,287 15,254,744 15,477,024 47,316,514

103,168,251

Average charges 398,139 283,751 331,625 368,501 606,622

433,480

Female 34% Cases 18 17 20 19 47 121 Total charges 8,334,942 6,255,147 8,468,037 8,246,989 28,738,590

60,043,705

Average charge 463,052 367,950 423,402 434,052 611,459 496,229 AGE Total Percent <1 9 3% 1-14 * * 15-24 5 1% 25-34 12 3% 35-44 36 10% 45-55 92 26% 55-64 142 40% 65-74 51 14% 75-84 11 3% 85+ * *

HCV diagnosis

Total Percent

Yes 75 21% No 284 79%

Payer Commercial Medicaid Medicare Other Self Pay

Cases 139 99 115 * 5

Percent 39% 28% 32% * 1% Total charges

60,132,569 50,703,469 49,969,333 * 2,010,731

Average 512,156 434,516 * 402,146


charges 432,608 Data source: Kentucky Cabinet for Health and Family Services, Office of Health Policy *Too few to report

Section 11: Deaths Hepatitis C – Underlying Cause of Death - Northern Kentucky Area Development District Northern Kentucky 2011 2012 2013 2014 2015 2011-15 Deaths 8 10 7 7 8 46 Death rate 1.8 2.2 1.6 1.6 1.8 2.1 Data source: Kentucky Vital Statistics Death Records

Section 11: Deaths Hepatitis C – Contributing Cause of Death –Northern Kentucky Area Development District Northern Kentucky 2011 2012 2013 2014 2015 2011-15 Deaths 19 22 20 23 33 117 Death rate 4.3 4.9 4.5 5.1 7.3 5.2 GENDER 2011 2012 2013 2014 2015 2011-15 Male 13 15 13 17 23 81 Female 6 7 7 6 10 36 Death rate Male

5.9 6.8

5.9

7.6

10.2

7.3 Female

2.7

3.1

3.1

2.6

4.4

3.2 AGE 2011 2012 2013 2014 2015 2011-15 0-14 0 0 0 0 0 0 15-24 0 0 0 0 0 0 25-34 * 0 0 0 * * 35-44 * 0 * 0 * 8 45-54 10 11 5 8 9 43 55-64 * 9 11 12 16 52 65-74 0 * 0 * * 6 75-84 * 0 * * 0 5 85+ 0 0 * 0 * * Case rate 2011-15 RACE 2011-

2015 Percent


0-14 0 White 114 97.4%

15-24 0 Black * *

25-34 * Other * *

35-44 2.69

45-54 23.22

55-64 18.57

65-74 3.69 75-84 6.22 85+ *

Data source: Kentucky Vital Statistics Death Records *Too few to report


Appendix 3: Utilization Plan Logic Model and Description of

Stakeholder Engagement


To assure that this report met the requirements of its intended audience, stakeholders were identified and invited to participate, via in-person meeting or online questionnaire, about the contents of the report and uses for the data.

Stakeholders were asked to complete a baseline survey. Nine responses were received. The following general perceptions were identified from those responses:

All indicated that they are able to identify at-risk populations for infection with the hepatits C virus.

Some currently utilize hepatitis C data in their work; even more would like to utilize hepatitis C data in their work.

Overall, most know where to access local, state and U.S. data for hepatitis C and access it via local health departments, the Kentucky Department for Public Health and CDC.

It is unclear if respondents can identify the number of cases of hepatitis C in the Northern Kentucky area.

There is interest in a Northern Kentucky task force for addressing local HCV transmission.

A discussion with stakeholders identified the following motivations for remaining involved in the efforts to control the hepatitis C epidemic in Northern Kentucky:

Serious outcomes from HCV infection (individual and community)

The general public does not fully understand this epidemic

Financial ramifications of the disease and treatments

Impact to children born to mothers with HCV

Recruitment of health care professionals into the field

Many younger people are infected

Having HCV does not make you immune to getting it again

A high burden of HCV can impact the future of children and grandchildren

Have we motivated independent providers to screen for HCV?

How closely tied is HCV to IDU, and specifically opioid use?

What if there is a breakdown in provider/infection control?

A discussion with stakeholders identified the following types of data that could be included in the report

Demographics (age, race/ethnicity, gender)

Location (ZIP code, county, comparison to Kentucky and U.S.) of those diagnosed

Mortality

Transmission/prevalence

Testing locations

Treatment (capacity, diagnosis versus treatment, health insurance)

Risk factors (HIV co-infection, genotype, incarceration, tattoos)


A discussion with stakeholders identified how they might utilize the data in this report in their current job responsibilities

Maintain education on transmission/prevention

Track prevalence

Increase access to testing locations

Ensuring access to treatment

Track number/percentage insured

Improve outcomes

Suggestions were taken on who would find the report useful, as well as where and how to disseminate the report.

Attempts were made to include all requested data, however strict timing constraints did not allow for inclusion of all data points. It is the intent of Northern Kentucky Health Department to update this report on a regular basis as resources allow with additional data as it becomes available and add content as trends change within the policies, systems and environment of Northern Kentucky.

Next steps include:

Presentation of the report to stakeholders.

Dissemination efforts will be designed, planned and implemented.

Documents

Hepatitis C Epidemiologic Profile for Northern KentuckyHepatitis C Epidemiologic Profile for Northern Kentucky 2017 Page 7 1. Introduction About the virus Acute hepatitis C virus infection