Birth Cohort Testing for Hepatitis C Virus - Indian Health Service 2012-2015.

Hepatitis C virus (HCV) infection is a substantial and largely unrecognized public health problem. An estimated 3.5 million persons in the United States are currently living with HCV infection, at least half of whom are unaware of their infection (1-3). Persons born during 1945-1965 (the "baby boomer" birth cohort) have a sixfold higher prevalence (2.6%) than adults of other ages, and represent 81% of all persons chronically infected with HCV (4). Therefore, in addition to recommending testing for all persons at risk for HCV infection, CDC and the U.S. Preventive Services Task Force (USPSTF) recommend one-time HCV testing for the birth cohort (5,6). Compared with the national average, American Indian/Alaska Native (AI/AN) persons have approximately twofold the rate of acute HCV incidence and HCV associated mortality (2). In June 2012, the Indian Health Service (IHS) implemented HCV testing in the 1945-1965 birth cohort and created a nationally standardized performance measure to monitor implementation of the recommendation. As of June 2015, the proportion of the birth cohort screened for HCV increased from a baseline of 7.9% (14,402/182,503) to 32.5% (68,514/211,014) among the AI/AN population served by IHS nationwide; provider training and the use of clinical decision tools were associated with increases in HCV testing. With this fourfold increase in testing in just 3 years, IHS needs to prepare for the challenges associated with increased identification of persons living with HCV infection.

Death rates from human immunodeficiency virus and tuberculosis among American Indians/Alaska Natives in the United States, 1990-2009.

OBJECTIVES: We used race-corrected data and comprehensive diagnostic codes to better compare HIV and tuberculosis (TB) mortality from 1999 to 2009 between American Indian/Alaska Natives (AI/ANs) and Whites. METHODS: National Vital Statistics Surveillance System mortality data were adjusted for AI/AN racial misclassification through linkage with Indian Health Service registration records. We compared average annual 1990 to 2009 HIV and TB death rates (per 100,000 people) for AI/AN persons with those for Whites; Hispanics were excluded. RESULTS: Although death rates from HIV in AI/AN persons were significantly lower than those in Whites from 1990 to 1998 (4.2 vs 7.0), they were significantly higher than those in Whites from 1999 to 2009 (3.6 vs 2.0). Death rates from TB in AI/AN persons were significantly higher than those in Whites, with a significant disparity during both 1990 to 1998 (3.3 vs 0.3) and 1999 to 2009 (1.5 vs 0.1). CONCLUSIONS: The decrease in death rates from HIV and TB was greater among Whites, and death rates remained significantly higher among AI/AN individuals. Public health interventions need to be prioritized to reduce the TB and HIV burden and mortality in AI/AN populations.

Pandemic influenza preparedness and vulnerable populations in tribal communities.

American Indian and Alaska Native (AIAN) governments are sovereign entities with inherent authority to establish and administer public health programs within their communities and will be critical partners in national efforts to prepare for pandemic influenza. Within AIAN communities, some subpopulations will be particularly vulnerable during an influenza pandemic because of their underlying health conditions, whereas others will be at increased risk because of limited access to prevention or treatment interventions.We outline potential issues to consider in identifying and providing appropriate services for selected vulnerable populations within tribal communities. We also highlight pandemic influenza preparedness resources available to tribal leaders and their partners in state and local health departments, academia, community-based organizations, and the private sector.

Implementation of National HIV Screening Recommendations in the Indian Health Service.

BACKGROUND: The Indian Health Service (IHS), a federal agency, provides direct patient care to an estimated 1.9 million American Indian/Alaska Native patients across a large and decentralized network of health facilities. The IHS sought to implement HIV screening of adults and adolescents per national recommendations. The IHS facilities received technical support such as electronic clinical reminders (ECRs) and sample HIV-testing policies. PURPOSE: To determine what facility-wide policy and practices were associated with high HIV screening rates. METHODS: Survey of clinical directors of 61 federal health facilities on use of ECRs, testing policies/standing orders, and other factors associated with HIV screening. These results were correlated with HIV screening performance results for each facility as derived from the IHS national database. RESULTS: A total of 51 (84%) of 61 facilities were interviewed. In univariate analysis, factors that were correlated with higher rates of HIV screening were having an HIV screening standing order (unadjusted odds ratio [UOR] 8.7, 95% confidence interval [CI] 2.0-37.3), sexually transmitted disease (STD) screening standing order (UOR 5, CI 1.1-21.7), having an HIV ECR in place for a year or longer (UOR 10.2, CI 2.8-37.5), and inclusion of both providers and nurses in offering HIV screening (UOR 4.8, CI 1.4-16.7). In multivariate analysis, ECRs (adjusted odds ratio [AOR] 9.1, 95% CI 1.8-45.1) and STD standing orders (AOR 7.4, 95% CI 1.1-51.0) remained significantly associated with higher HIV screening. CONCLUSION: Policy and practice interventions such as ECRs and standing order/testing policies and delegation of screening are correlated with high HIV screening, are scalable across health networks, and will be used for improving other infectious disease screening indicators in such as STD and hepatitis C.

Within the hidden epidemic: sexually transmitted diseases and HIV/AIDS among American Indians and Alaska Natives.

OBJECTIVES: To review the epidemiology, research, and prevention programs for sexually transmitted diseases in American Indians and Alaska Natives (AI/ANs). STUDY DESIGN: We reviewed the current national and regional trends in sexually transmitted diseases (STDs) for AI/ANs from 1998-2004, peer-reviewed studies from January 1996, through May 2006, and reports, unpublished documents, and electronic resources addressing AI/AN STD prevention and control. RESULTS: STD prevalence among AI/ANs remains high. For example, the case rate of C. trachomatis in the North Central Plains AI/AN populations is 6 times the overall US rate. Trends for C. trachomatis also show sustained increases. Little research exists on STDs for this population, and most is focused on HIV/AIDS. Fear of compromised confidentiality, cultural taboos, and complex financial and service relationships inhibit effective surveillance, prevention, and management. CONCLUSIONS: Recommendations for STD control in this population include improved local surveillance and incorporation of existing frameworks of health and healing into prevention and intervention efforts. Research defining the parameters of cultural context and social epidemiology of STDs is necessary.