Viral Hepatitis Prevention and Control in the U'S'

1
Viral Hepatitis Prevention and Control in the
U.S.

• Digestive Disease National Coalition
• March 8, 2009
• Washington, DC

2
Global Disease Burden
Chronic HBV 370 million Chronic HCV 130
million HIV 40 million

3
U.S. Disease Burden

• Living with chronic viral hepatitis 4.5 M
• Living with HIV 1.1 M
• Unaware of viral hepatitis infection gt2 M
• Unaware of HIV status 200,000
• Deaths from chronic viral hepatitis 11-15,000
• Deaths from HIV/AIDS 12,500

4
U.S. Disease Burden

• 4th leading ID cause of premature mortality
• Health disparities for minority populations
• Of Black men 40-49 yrs, one in 7 HCV infected
• Of Asian Americans one in 12 HBV infection
• Cause of 70 of chronic liver disease
• Most common cause of liver transplantation
• Liver cancer is 9th leading cause of cancer
  deaths and increasing

5
Strategic Imperatives for Viral Hepatitis
Prevention and Control

• Protect vulnerable populations from infection
• Prevent disease from chronic hepatitis B and
  hepatitis C
• Gather data to guide disease prevention

6
Division of Viral Hepatitis

• Three funding lines
• Viral hepatitis
• Emerging infections
• Food safety

7
Domestic HIV, Viral Hepatitis, STD and TB
Prevention Appropriated Funds, FY 2008
Domestic HIV 69
STD 15
TB 14
Hepatitis 2
Total 1 billion
8
Institute of Medicine Review

• Strategies for preventing HBV and HCV infections
• Strategies for reducing morbidity and mortality
  from chronic HBV and HCV infections
• Assess the type and quality of data needed from
  state and local viral hepatitis surveillance
  systems to guide and evaluate prevention services

9
DVH Needs Assessment for Viral Hepatitis
Prevention

• Priorities
• Improve detection of viral hepatitis
• Reduce illness and death from viral hepatitis
• Eliminate HBV transmission among adults in the
  U.S.
• Prevent HBV transmission and disease among HBV
  infected pregnant women and their infants

10

• Systems for Viral Hepatitis Surveillance
• Passive surveillance nationwide for acute disease
  via the National Notifiable Disease Surveillance
  System (NNDSS)
• No dedicated extramural program funding
• Reporting incomplete
• Enhanced surveillance in selected sites
• Sentinel Counties (1982 2006)
• Enhanced Hepatitis Surveillance Centers (2005
  present) to integrate acute and chronic disease
  activities, develop best practices, and
  estimate/evaluate disease burden

11
States Reporting Chronic Hepatitis B and C Virus
Infections via NNDSS, 2007
Chronic HBV Infection
Chronic HCV Infection
Reports to CDC
Not reportable
Reportable but reports not sent to CDC
12
Comparison of National Chronic Disease
Surveillance Systems

• System Est. no. No. reports/
  Reporting Est. Case Est. Data
• Coordinator infected year
  flow Complete Complete
  Funding
• HIV/AIDS 50,000-
  MD/lab?all
• (HARS)CDC 1.2 m 60,000
  SHDs?CDC gt85 gt90
  50 m
• Cancer
  MD?Cancer
• (NPCR)CDC - 1.2 million
  registr.?CDC gt95 gt95
  38 m
• End-stage renal
  Medicare
• Disease (USRDS)
  data ?
• NIDDK 2.0 m 100,000
  NIDDK 100 gt95
  3 m
• Chronic HBV
  labs?39 lt10
  sex 99
• (NNDSS)CDC 1.2 m 20,000 SHDs
  ?CDC race/eth30-45 0
• Chronic HCV
  labs?36 lt10
  sex 99
• (NNDSS)CDC 3.2 m gt100,000 SHDs
  ?CDC race/eth 25-40 0

13
Percentage of Missing Data from Viral Hepatitis
Case Records, U.S., 2005-2007
Source National Notifiable Disease Surveillance
System (NNDSS)
14
Improve Detection Of Viral Hepatitis

• Quality case surveillance
• Outbreak detection and investigation
• Monitoring viral mutations
• Linkage to other systems
• Disease registries
• Health targets
• Eliminate the backlog of case reports
• help states and CDC effectively monitor viral
  hepatitis morbidity and mortality
• Identify outbreaks in healthcare and other
  settings
• Strengthen capacity in 4 regional public health
  labs to support outbreak investigations.

15
Non-hospital healthcare-associated HBV and HCV
infection

• 33 outbreaks in past 10 years in non-hospital
  healthcare settings
• outpatient medical or surgical clinics (n12)
• chronic hemodialysis centers (n 6)
• Long term care facilities (n15)
• gt 450 new HBV or HCV infections identified
• Is this the tip of the iceberg?
• gt60,000 persons recommended for screening
• Infection control breaches by healthcare
  personnel
• These outbreaks continued despite available
  recommendations

16
Reduce Illness/Death from Viral Hepatitis

• Viral Hepatitis Intervention Program
• Screening and counseling
• Culturally competent outreach
• Professional training
• Case management
• Integrate with STD services
• Capacity to respond to emerging trends
• Healthcare associated viral hepatitis
• HCV in HIV MSM
• Immigration
• Goal - Identify and care for 100,000 HCV persons
  and 40,000 HBV persons

17
Reduce Illness/Death from Viral Hepatitis

• Adult viral hepatitis coordinators
• Average award 90,000
• VH-NET cooperative agreements
• 6 nationally _at_150,000 per year
• Screening, testing, counseling
• 0 federal funds dedicated to these activities

18
Eliminate HBV Transmission Among Adults In The U.S

• Support personnel in the Adult Hepatitis B
  Vaccination Initiative
• Assure initiation and completion of hepatitis B
  vaccination series in 1700 clinics
• Conduct or refer for other viral hepatitis
  prevention services
• Develop or augment IT systems
• Program evaluation
• Health target Increase vaccination coverage by
  30 among at risks adults

19
Prevent HBV Transmission And Disease Among
Pregnant Women And Their Infants

• Augment case management of perinatal prevention
  programs for
• Infants
• Mothers
• Family and household members
• Health targets
• Eliminate HBV transmission among infants born in
  the U.S.
• Eliminate HBV transmission among family members
  of HBV pregnant women
• Prevent progression of HBV-related liver disease
  among HBV pregnant women

20
Challenges for Prevention and Control of
Chronic Viral Hepatitis in the U.S.

• Achieve goal of eliminating HBV transmission
• Reduce HCV transmission
• Assure all persons w/ HBV HCV infection
• Know their infection status
• Receive appropriate care and treatment
• Have reduced risk of liver cirrhosis and cancer
• Prioritize services to eliminate racial/ethnic
  health disparities
• Asian/Pacific Islanders
• African Americans
• Strengthen surveillance and evaluation