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Cluster of Sexually Transmitted Hepatits C Virus Among the MSM Population in Southeast Michigan [Detroit]
  STD Conference
Thursday, September 22, 2016: 11:30 AM
Room 208/209
Jenny Gubler, MS1, Sandra Johnson, BS2 and Joseph Coyle, MPH1, 1Commumicable Disease Divison, Michigan Department of Health and Human Service, Lansing, MI, 2STD Surveillance and Intervention, Michigan Department of Health and Human Service, Detroit, MI
Background: Hepatitis C Virus (HCV) is a blood-borne pathogen that is rarely transmitted sexually among monogamous heterosexual couples. However, risky behaviors among men who have sex with men (MSM) (e.g. fisting, use of sex toys, anal douching), particularly in the presence of HIV infection and/or ulcerative STDs, have been associated with increased risk of sexual transmission of HCV. We report on a cluster investigation of sexually transmitted HCV in the MSM population in Southeast Michigan; a rare occurrence in the United States.
Methods:In February 2016, an astute clinician notified the Michigan Department of Health and Human Services (MDHHS) about an increase in HCV diagnoses in their HIV-infected MSM population. MDHHS began an investigation to determine the scope of the HCV infections, utilizing the Detroit Disease Intervention Specialists (DIS) to solicit cases and contacts and recommend testing for HCV antibody and RNA. Demographic, clinical, and risk factor information were captured to inform the epidemiological investigation
Results: As of June 27, 2016 there were 19 cases in the cluster, with several dozen contacts still under investigation . All nineteen of the cases were male and 18 were African American with one Hispanic. All nineteen were infected with HIV, 18 reported never injecting drugs and 19 reported having sex with men. A history of having an STD was common - syphilis (15), gonorrhea (12), chlamydia (11), and lymphogranuloma venereum (5). Many HCV infections were acute or new seroconversions suggesting recent infection and of 9 isolates that underwent genotyping, all were HCV genotype 1a
Conclusions:The Detroit DIS have been crucial in enhancing the capacity of the State’s Viral Hepatitis Program in contact tracing cases and contacts and referral to HCV testing and treatment services. Additional molecular characterization of the HCV specimens along with patient interviews will help further determine HCV transmission patterns in this community
HCV Cluster Sexually Transmitted
Michigan probing 22 cases in rare occurrence

by Michael Smith
North American Correspondent, MedPage
Action Points
º Note that this study was published as an abstract and presented at a conference. These data and conclusions should be considered to be preliminary until published in a peer-reviewed journal.
º A cluster of sexually transmitted Hepatitis C Virus (HCV), a rare occurrence in the U.S., is being investigated in a population of HIV- positive men who have sex with men (MSM) in Southeast Michigan.
º Note that while HCV, a bloodborne pathogen, is most commonly transmitted in the setting of injection drug use, it can also be transmitted from mother to child, by unregulated tattooing, and by sexual contact involving blood.
ATLANTA -- Michigan officials are probing a rare cluster of what appears to be sexually transmitted hepatitis C (HCV), a researcher said here.
As of Sept.14, the cluster includes 22 confirmed cases and 11 suspected cases in Detroit and three neighboring counties, according to Jenny Gubler, MS, a viral hepatitis epidemiologist with the Michigan Department of Health and Human Services in Lansing.
And another 30 or more sexual contacts of the cases are being investigated, Gubler reported at the 2016 STD Prevention Conference.
HCV, a bloodborne pathogen, is most commonly transmitted in the setting of injection drug use, Gubler noted, although it can also be transmitted from mother to child, in healthcare settings, and by unregulated tattooing.
Importantly, she added, it can also be transmitted by sexual contact involving blood.
Gubler told that all but one of the case patients in the cluster -- all men who have sex with men (MSM) and all HIV-positive -- have none of the usual risk factors for HCV, including using injection drugs.
The exception, was one person who admitted injection drug use but Gubler said it was very recent and is probably not the cause of his infection.
The CDC says that HCV is "not efficiently transmitted through sex (but) high-risk and traumatic sexual practices," especially among MSM, can increase the risk, as can genital ulcerative disease, HIV, and a large number of sexual partners.
But the focus recently has been on the burgeoning epidemic of opioid abuse, which has led to outbreaks of HCV in many places.
While sexual transmission of HCV is regarded as rare, it's not unheard of, commented Thomas Peterman, MD, of the CDC, who was not part of the study but who moderated the session at which it was presented.
"There's some evidence of sexual transmission elsewhere," he told MedPage Today. A cluster was reported among men who have sex with men in New York City in 2005 to 2010 and other reports have come from Europe.
"What's new about this is not that there is sexual transmission," he said, "but that they've been able to investigate it."
The investigation began in February, Gubler reported, when an alert nurse practitioner noticed 6 patients who had recently undergone HCV seroconversion but with no history of injection drug abuse.
She alerted the state health department, which used its health surveillance system to find more cases by matching HCV case reports to HIV patients in the Electronic HIV/AIDS Reporting System.
And disease intervention specialists in Detroit found more cases, Gubler said. She and colleagues defined a case as an MSM with a recent HCV seroconversion, who is HIV-positive, has no history of injection drug use, and is living in southeastern Michigan.
Suspect cases are those in which the HCV testing is incomplete or the absence of other risk factors is unclear, she said, while contacts are defined as any sexual contact of a case patient since 2014.
All of the case patients are under care for their HIV, she said, but only about half are virally suppressed. They range in age from 21 to 48 and 21 of the 22 cases are African American. Most have a history of other sexually transmitted infections.
The investigation involves "a lot of red tape" as officials try to navigate through different jurisdictions and reporting systems with limited resources, Gubler said. "This is probably no surprise but we don't have enough staff for this," she said.
One unusual feature of the investigation is the use of disease intervention specialists to trace and investigate contacts. "This is kind of a novel situation," Gubler said, "because typically you don't perform contact tracing for HCV cases."
To complicate matters, she added, the region is also dealing with an outbreak of Lymphogranuloma venereum in its MSM community.

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