Hepatitis Prevention and Control: National Update Blood Borne: A Silent Epidemic Chicago, IL October

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Hepatitis Prevention and ControlNational
UpdateBlood Borne A Silent Epidemic Chicago,
ILOctober 26-27, 2006Joanna Buffington, MD,
MPHDivision of Viral HepatitisNational Center
for HIV, Hepatitis, STD, and TB Prevention
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Acute Viral Hepatitis, United States, 2001-2004
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34
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Hepatitis A
Hepatitis B
Hepatitis C
Non-ABCDE
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Source Sentinel Counties Study, CDC
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Reported Cases of Selected Notifiable Diseases
Transmitted by Sex or Blood, 1998 vs 2004
1998 2004 Hepatitis A 23,229
5,683 Hepatitis B(acute) 10,258
6,212 Hepatitis C(acute) 720 AIDS/HIV
46,521 44,108 Chlamydia 604,420 929,462 Syphi
lis (PS) 6,993 7,980 Gonorrhea 355,64
2 330,132
Fecal-oral
Source National Notifiable Diseases Surveillance
System
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Reported Cases of Selected Notifiable Diseases
Preventable by Vaccination, U.S., 1998 vs 2004
1998 Pertussis 7,405 Hepatitis
A 23,229 Hepatitis B 10,258 H. Influenza
1,194 Measles 100 Meningococcal
2,725 Mumps 666 Rubella 7
2004 25,827 5,683 6,212 2,085
37 1,361 258 10
Source National Notifiable Diseases Surveillance
System, varicella 2004 32,931
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Hepatitis A
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Hepatitis A Virus Transmission

• Fecal-oral
• Close personal contact(e.g., household contact,
  sex contact,child day care centers, illegal drug
  sharing)
• Contaminated food, water(e.g., infected food
  handlers, raw shellfish)
• Blood exposure (rare)(e.g., injecting drug use,
  transfusion)

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Risk Factors Associated with Reported Hepatitis
A, 1990-2000, United States
Source NNDSS/VHSP
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Risk Factors for Hepatitis A Outbreak, Polk
County, FL, Jan01 Jul 02 n403
Men who have sex with men 1
Injected drug use
Day care 5
Personal contact
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14
Non injected drug use 37
Foodborne outbreak (4)
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Unknown
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Recommendations for Hepatitis A Vaccine
Persons at increased risk of infection or its
adverse consequences

• Travelers to HAV endemic countries
• Men who have sex with men (MSM)
• Illegal drug users
• Persons with chronic liver disease
• Persons with clotting factor disorders
• Persons who work with HAV in lab

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Nationwide Vaccination of Children

• All children should receive hepatitis A vaccine
  at 1 year (i.e., 12-23 months). Vaccination
  should be integrated into routine childhood
  vaccination schedule. Children not vaccinated by
  age 2 can be vaccinated at subsequent visits.
• Areas with existing hepatitis A vaccination
  programs for children 2-18 years are encouraged
  to maintain them new efforts for routine
  vaccination of 1 year olds should enhance, not
  replace, ongoing programs.
• In areas without existing programs, catch-up
  vaccination of unvaccinated children 2-18 years
  can be considered. Such programs might be
  warranted in the context of rising incidence or
  ongoing outbreaks among children or adolescents.

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Hepatitis A Incidence, United States, 1980-2004
Provisional rate
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Hepatitis A Reported Incidence by Age, 1990-2004
Source NNDSS
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Hepatitis A Incidence by Race/ethnicity 1990-2004
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Hepatitis B
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Concentration of HBV in Body Fluids
Moderate semen vaginal fluid saliva
Low/not detectable urine feces sweat tears breastm
ilk
High blood serum wound exudate
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Transmission of HBV

• Perinatal
• Sexual
• Percutaneous

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• Reported Risk Factors for
• Hepatitis B, United States, 2005

Medical employee
Household contact
Surgery/Health Care
Sexual contact
Homo and bisexual men
Homo and bisexual men w/ multple partners
Injection drug user
Multiple sex partners (hetero)
50 of cases are missing risk factor data Source
Nationally Notifiable Diseases Surveillance System
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Incidence of Hepatitis B, by Age and Sex, United
States, 2005
Age (Years)
Incidence
Women
Men
0.0
0.0
lt5
5-9
0.0
0.0
10-14
0.0
0.0
15-19
0.4
0.4
20-24
2.0
1.5
25-29
4.0
2.6
30-34
2.8
3.7
35-39
4.1
2.7
40-44
2.1
4.2
45-49
2.0
3.1
50-54
2.7
1.4
55-59
2.1
1.2
60
1.1
0.5
Source National Notifiable Diseases Surveillance
System (NNDSS)
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Self-Reported Adult Hepatitis B Vaccine Coverage,
2004
60
1999 Vaccination of 0-18 y.o. recommended
50
40
30
Vaccine coverage,
20
10
0
18-20
21-25
26-30
31-40
41-49
Age group, years
Source CDC, National Health Interview Survey,
MMWR May 2006
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Self-Reported Adult Hepatitis B Vaccine Coverage,
2004
1999 Vaccination of 0-18 y.o. recommended
60
50
35 45
40
30
Vaccine coverage,
20
10
0
18-20
21-25
26-30
31-40
41-49
TOTAL

• All Adults 18-49
• Adults at high risk

Age group, years
Includes persons reporting risks as listed in
MMWR article. Source CDC, National Health
Interview Survey, MMWR May 2006
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Hepatitis B Vaccine Coverage, by Group
Sources Self-reported data from National Health
Interview Survey (NHIS), 2003 National Health
and Nutrition Examination and Survey (NHANES),
1999-2002 Demonstration project, San Diego
VHIP, Denver
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Prior Opportunities For Vaccination Among
Patients With Acute Hepatitis B, 2001-2004
Source Sentinel Counties Study of Viral
Hepatitis (n591)
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ACIP Recommendations for Hepatitis B Vaccination
of Adults

• Hepatitis B vaccination is recommended for
• All unvaccinated adults at risk for HBV infection
• All adults seeking protection from HBV infection
• acknowledgment of a specific risk factor is not a
  requirement for vaccination

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Persons with Sexual Risk

• Sexual partners of HBsAg-positive persons
• Sexually-active persons not in a long term,
  mutually monogamous relationship (gt1 partner in 6
  mo)
• Persons evaluated/treated for STDs (including
  HIV)
• Men who have sex with men

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Percutaneous or Mucosal Risk

• Household contacts of HBsAg positive persons
• Injection-drug users
• Healthcare and public safety workers
• Persons with endstage renal disease, including
  pre-dialysis, hemodialysis, peritoneal dialysis,
  and home dialysis patients

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Incidence of Acute Hepatitis B United States,
1980-2005
80 decline in incidence since 85
Source National Notifiable Diseases Surveillance
System (NNDSS)
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Reported Acute Hepatitis B by Age, United
States, 1990-2005
0-11 years old
20 years old
98 decline
76 decline
12-19 years old
97 decline
Source National Notifiable Diseases Surveillance
System (NNDSS)
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Hepatitis B Incidence 19 YearsBy
Race/Ethnicity United States, 1990-2004
Black
Asian/Pacific Islander
AI/AN
Hispanic
White
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ImplementationGuidance
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Implementation Recommendations

• Setting-specific vaccination strategies to
  achieve high coverage among persons recommended
  to be vaccinated
• Doctors offices primary-care and specialty
  medical settings
• Higher prevalence settings
• Occupational health settings

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Higher Prevalence Settings Vaccination
Recommended For All Adults

• STD treatment facilities
• HIV testing, treatment facilities
• Facilities providing drug abuse treatment and
  prevention
• Correctional facilities
• Health care settings serving MSM
• Chronic hemodialysis facilities and endstage
  renal disease programs
• Institutions and nonresidential daycare
  facilities for developmentally disabled persons

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Higher Prevalence Settings Targeting All Clients
for Vaccination

• Assume all unvaccinated adults are at risk
• Vaccinate as a component of STD, HIV/AIDS, and
  other prevention and clinical services
• When feasible, vaccinate in outreach settings

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Hepatitis B Vaccination In High-Prevalence
Settings

• Demonstration projects have established
• feasibility of vaccinating as part of STD and
  HIV/AIDs prevention services, 1st dose acceptance
  75-85
• program components required to successfully
  implement adult hepatitis B vaccination
• Funding for vaccine and administration is primary
  barrier to implementation in these settings

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Barriers and Strategies Infrastructure
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Barriers and Strategies Providers and Patients
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Barriers and Strategies Resources
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Summary

• Adult hepatitis B rates have declined by gt70
  since 1990
• Expect continued decline with aging of vaccinated
  cohorts of infants, children and adolescents
• Elimination of HBV transmission can be
  accelerated by increasing vaccination coverage
  among at-risk adults
• 85 of cases among persons with risk
  characteristics
• Recommendations provide
• Setting-specific implementation strategies to
  achieve high vaccination coverage among at risk
  adults
• Recommendations to overcome barriers to
  vaccination

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Hepatitis C
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Estimated Incidence of Acute HCV, U.S.
N240,000/yr
Decline in injection drug users
N30,000
Decline in transfusion recipients
?
Source Armstrong GL. Hepatology 200031777-82
Alter MJ. Hepatology 19972662S-65S CDC,
unpublished data
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Prevalence of HCV Infection in the General
Population by Age, U.S., 1988-2002
Source NHANES Alter MJ, NEJM 1999341556-562
Armstrong GL, Ann Intern Med 2006, in press
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Chronic hepatitis B cases reported to NNDSS,
2002-2006
2006 estimated, 28 states reporting
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Chronic hepatitis C cases reported to NNDSS,
2002-2006
2006 estimated, 28 states reporting
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Relative Importance of Risk Factors for Remote
and Recent HCV Infection
Remote (gt20 yrs ago)
Recent (lt20 yrs ago)
Injection Drug Use
Injection Drug Use
Transfusion
Unknown
Sexual
Transfusion
Other
Unknown
Other
Sexual
Nosocomial, occupational, perinatal
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Risk of HCV, HBV Infection Among Injection Drug
Users in Two Time Periods
Baltimore 1983-88
HCV
HBV
Five US Cities 2002-04
HCV
HBV
Garfein RS Am J Public Health 1996 86655
Collaborative Injection Drug User Study III
(CIDUSIII)/Drug Users Intervention Trial (DUIT)
Baltimore, Chicago, Los Angeles, New York City,
Seattle. CDC unpublished data.
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Hepatitis C Control (and HIV!) Key Factors

• Goal 1 Prevent new infections
• Educate, train, counsel to prevent initial
  infection, transmission
• Goal 2 If infected, prevent chronic liver
  disease, complications
• Identify who is infected
• Test people at risk get them the results!
• Refer for medical, social, substance abuse
  treatment
• Counsel for healthier living, alcohol
• Immunize for other infections that can harm the
  liver
• Reducing transmission
• Stop injecting
• Dont initiate new injectors
• Dont share anything (HCV)

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Strategies

• Collaborate
• Federal CDC, SAMHSA, HRSA
• State C coordinators, HIV, STD, IZ, corrections,
  mental health, substance abuse, alcohol programs
• Integrate
• Comprehensive language into program
  announcements and guidance for services (NYC
  example)
• National, regional, state, and local conferences
  and programs
• Communicate
• www.cdc.gov/hepatitis
• Community organizations and partners
• Share the stories to get the messages across
• CDC to update Guidelines for Prevention and
  Control

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Path from Screening for Hepatitis C to Treatment
What Can YOU Do?
Identify HCV infected patients
Counseling/ Harm Reduction
Medical Evaluation
Liver biopsy
Support group
Treatment
HCV Infection
Cure

• Vaccines
• A, B
• Influenza
• Pneumococcal
• Alcohol/ other substance abuse
• General health
• -Prevent transmission

Confirmation of Screening Tests
HCV Treatment Evaluation
Receive test results
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Elements of New York States Comprehensive
Approach

• Comprehensive Strategic Plan
• Hepatitis Integration Project Integrate
  hepatitis prevention and treatment into existing
  services for IDUs
• Community settings syringe exchange programs,
  syringe access, community outreach
• Medical settings substance use and HIV
  treatment sites
• Correctional settings
• Adult Hepatitis Vaccination Program
• Reimbursement
• Training for clinical and non-clinical providers
• Clinical Guidelines and Quality of Care monitoring

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New York State Viral Hepatitis Strategic Plan

• Developed with state-wide input
• Government State health, substance use
  treatment, corrections, laboratory,
  countyhealth departments, VA
• Providers HIV, substance use treatment
• State-wide associations medical society,
  managed care
• Consumers
• Prevention priorities
• Increase awareness and knowledge of viral
  hepatitis
• Develop standard protocols for screening,
  testing, counseling, vaccination, referral and
  treatment
• Integrate viral hepatitis prevention into
  existing programs serving IDUs.

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Viral Hepatitis Training National Viral
Hepatitis Training Center

• New York State is the recipient of a 3-year
  cooperative agreement from CDC
• Goal is to develop a National Hepatitis A, B, C
  Training Curriculum for workers in substance use
  treatment, corrections and community-based
  settings.
• Year 1 training needs assessment
• Year 2 Training development and piloting
• Year 3 National role out training of trainers
  (TOT)

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Updated Recommendations and Guidelines

• www.cdc.gov/hepatitis
• Hepatitis A new ACIP guidelines May 2006
• http//www.cdc.gov/mmwr/pdf/rr/rr5507.pdf
• Hepatitis B new ACIP guidelines December 2005
  (childhood) http//www.cdc.gov/mmwr/pdf/rr/rr5416
  .pdf
• Hepatitis B new ACIP guidelines November 2006
  (adult)
• 2006 STD Treatment Guidelines (August 2006)
• http//www.cdc.gov/std/treatment/2006/toc.htm
• Hepatitis C updating 1998 recommendations (in
  progress)
• Clarify unknown/no data groups for testing
• Primary care medical home

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CDC Educational and Training Resources

• Website cdc.gov/hepatitis
• Web-based HCV training for professionals
• Web-based hepatitis serology course
• Brochures, posters, slide sets, videos
• Links to hepatitis education and training
  resources from our partners

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Electronic Surveillance Resources

• Case definitions
• http//www.cdc.gov/epo/dphsi/casedef
• Surveillance guidelines
• http//www.cdc.gov/ncidod/diseases/hepatitis/resou
  rce/index.htmsurveillance
• Hepatitis surveillance reports
• http//www.cdc.gov/ncidod/diseases/hepatitis/resou
  rce/index.htmsurveillance
• MMWR Annual Summaries
• http//www.cdc.gov/mmwr/summary.html