HCV & Native American Peoples in the United States,* by Alan Franciscus

Foreword
The prevalence of hepatitis C (HCV) in the Native American population in the United States is believed to be higher than in the general population. Unfortunately, there have been very few research papers on Native Americans and hepatitis C.  This article will discuss three papers that have been published.   

North America1
The first paper examined the prevalence of hepatitis C in indigenous peoples of Alaska. This included the Yupik, Inupiat and Aleut peoples who comprise 14.9% of Alaska’s population. 
By comparison, Indigenous Americans who live within the continental United States comprise approximately 1.2% of the population.  A review by the Indian Health Services (IHS) clinics in Arizona of 1496 people reported a prevalence of 16%.  In California, the IHS reported a 36.3% prevalence in a study of 344 persons.4 

IHS/CDC Review2
In another journal article2 the Indian Health Services (IHS) and the Centers for Disease Control and Prevention (CDC) conducted a chart review of two IHS clinical facilities.  The review was of American Indians (AIs) and Alaska Natives (ANs) 18 years old or older seen in primary care clinics between October 01, 2001 through September 30, 2003.

The mean age of the people (mostly male) in the study was men~40yo, women~42yo; the population came from 57 different American Indian tribes. 

There were 35,712 AI/AN patients of whom 251 patients (1%) had at least one HCV code sent in.  An HCV EIA (antibody) test was sent in for 209 (83%) patients, and 203 of these (99%) were antibody positive.  Confirmatory testing was performed in 144 of the 203 (70%) antibody-positive patients.  HCV RNA or viral load was confirmed in 144 patients (100%). 

The self-reported risk-factors were injection drug use (41%); no risk factor reported (38%); blood or blood products from before 1992 (9%); sexual contact (3%); other (6%); household contact (3%).
The key points of the study outcomes included:
The Omaha Clinic3
A study was conducted in Omaha, NE at the Fred LeRoy Health and Wellness Center.  A total of two hundred and forty-three Native Americans were screened (161 females; 82 males).  The mean age was 41 ± 1 yo.  Over 30 tribes from across the United States were seen at the clinic and represented in the study. The majority of the participants lived in an urban environment—only seven participants (2.9%) lived on an Indian reservation.  The participants were also asked to fill out a risk factor assessment. 

The study participants were screened for HCV antibodies and a follow-up HCV RNA (viral load) test was performed to confirm active HCV infection.  If a participant received an HCV RNA positive result a one-on-one counseling session with a physician to discuss the possible consequences of HCV was offered, as well as treatment options and counseling on the importance of avoiding alcohol.  A referral to a hepatologist for further monitoring and possible treatment was also offered.
 
Results: The overall results showed that there was an HCV antibody positive rate of 11.5% (8.1% females; 18.3% males) and the HCV RNA results were reported at 8.6% (6.2% females; 13.4% males).  All the participants who tested HCV RNA positive were between the ages of 30 to 59 years old (30-39 (13.3%); 40-49 (12.0%); 50-59 (14.3%).
 
Risk Factors: Injection drug use was the number one risk factor followed by receiving a tattoo more than 5 years ago, having sex with an HCV positive person, alcoholism, any transfusion, any tattoo and receiving a blood transfusion before 1992.

Importantly, participation in a Sun Dance ritual was not a significant factor.  The Sun Dance ritual is a Sioux ceremony that is practiced by many Great Plains Indians.  It includes “flesh offerings,” where 1 or more incisions are made in the skin of those participating in the ceremony.  In the past, one knife was used, but now tribal-sponsored ceremonies use only sterile, surgical scalpels.

The study is ongoing and more data will be collected.  The authors also stated that more studies are needed in larger Native American populations. 
The purpose of these future studies will be to:
A special thank you to Lora L. Langley, RN, BSN for providing a short overview of the study and providing participants with a copy of the journal article. 

Conclusion
There is clearly a need for more studies to understand the true prevalence of hepatitis C in the Indigenous Peoples of America.  There has not been a published study on the new direct acting antiviral therapies to treat Indigenous Americans.  But since the new therapies have similar cure rates across all races and ethnicities, it is expected that the newer therapies will be just as effective in Indigenous Americans infected with hepatitis C.   

*A future article will focus on Indigenous Peoples of Canada
 
Footnotes:
  1. Hepatitis C Virus in American Indian/Alaskan Native and Aboriginal Peoples of North America by J. D. Rempel and J. Uhanova
  2. Journal of Health Disparities Research and Practice Volume 3, Number 3, Number 2, Fall 2009, pp. 59-66 titled Hepatitis C Diagnoses in an American Indian Primary Care Population
  3. A.S. Neumeister, et al.  Hepatitis-C Prevalence in an Urban Native-American Clinic:  A Prospective Screening Study.  Journal of the National Medical Association, vol. 99, no.4
  4. Numbers in red are corrected from original Advocate article.
http://hcvadvocate.org/news/newsLetter/2014/advocate1214_mid.html#3

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