Prevention of Hepatitis C Virus Infection: Achievement through Integration into Established Prevention Programs

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Prevention of Hepatitis C Virus Infection
Achievement through Integration into Established
Prevention Programs

• Harold S. Margolis, M.D.
• Division of Viral Hepatitis
• National Center for Infectious Diseases
• Centers for Disease Control and Prevention
• Atlanta, GA

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Reasons to Combine Viral Hepatitis, HIV/AIDS and
STD Prevention

• Major public health problems
• Routes of transmission overlap substantially
• Effective prevention tools
• Immunization, risk and harm reduction, treatment
• Well established prevention programs
• STD, HIV/AIDS, drug treatment and prevention,
  corrections health
• Lack of integrated prevention activities leads to
  transmission of viral hepatitis

Hepatitis C the tipping point for a new
direction in prevention
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Disease Burden from Bloodborne Viral Infections,
United States
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Risk Factors for Transmission of Hepatitis
Viruses and HIV, United States
Proportion of Infections ()
Risk Factor
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Routes of Transmission andOpportunities for
Prevention of Infection with Hepatitis Viruses
and HIV Overlap Substantially
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Integration of Viral Hepatitis Prevention
Relative Disease Burden in Various Settings
Setting HBV HCV HIV
STD clinic
HIV/AIDS CT sites
Drug Treatment
Corrections
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Prevention Activities

• Primary (Identify person at risk of infection)
  Prevent HCV Acquisition
• high risk activities - IDU, high risk sex
• nosocomial, transfusions and transplant,
  occupational
• Secondary (Identify infected persons) Reduce
  Risk of Transmission to Others
• Test, counsel - harm reduction
• Tertiary (identify infected persons) Reduce
  Risk of Chronic Liver Disease
• Test, counsel - medical management

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Injecting Drug Use and HCV Infection

• Highly efficient mode of transmission
• Rapidly acquired after initiation
• Four times more common than HIV
• Prevalence 50-90 after 5 years
• Predominant risk factor in low prevalence
  countries

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Risk of Bloodborne Virus Infections Injection
Drug UsersBaltimore 19831988
HCV
HBV
Seroprevalence ()
HIV
Duration of Injecting (months)
Garfein RS. Am J Public Health. 199686655.
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Injecting Drug Use and HCV Infection

• Low endemic countries
• Major risk factor for infection
• Moderate/High endemic countries
• sentinel event for emergence of injecting drug
  use
• 50 of persons with acute hepatitis C (Italy,
  Russia)
• 40 of HCV-positive persons lt40 yrs old vs. 0
  gt40 (Italy)
• 2/3 of HCV-positive commercial blood donors
  (Egypt)

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Injecting Drug Use and HCV Infection

• Acquisition of HCV infection (not HIV) among
  injection drug users should become the
  Indicator of effective prevention programs
• Prevention of HCV infection (and viral hepatitis
  A and B) should be included in all substance
  abuse programs

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Transmission of Viral Hepatitis by Unsafe
Injections and Medical Practices
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Post-transfusion Hepatitis

• In developing countries, most transfused units
  not tested for HBV or HCV
• Related donors often used perception that less
  likely to be infected
• Inappropriate use of blood and blood products
  single unit transfusions common
• Lack of organized transfusion services
• Paid donors continue to be used in many countries
  

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Health-Care Related HCV Transmission

• Unsafe injection practices
• inadequate sterilization of reusable needles and
  syringes
• sharing of disposable needles and syringes
• high frequency of injections
• contamination of multi-dose vials
• Contaminated equipment
• lack of universal precautions
• inadequate cleaning and disinfection
• in health care settings
• alternative medicine practices, rituals

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Prevention Activities

• Primary (Identify person at risk of infection)
  Prevent HCV Acquisition
• high risk activities - IDU, high risk sex
• nosocomial, transfusions and transplant,
  occupational
• Secondary (Identify infected persons) Reduce
  Risk of Transmission to Others
• Test, counsel - harm reduction
• Tertiary (identify infected persons) Reduce
  Risk of Chronic Liver Disease
• Test, counsel - medical management

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Reasons to Identify Persons with Chronic HCV
Infection

• Counsel to prevent disease transmission
• household contacts
• sexual contacts
• drug use contacts
• Medical management
• evaluate for chronic liver disease
• treatment if indicated
• substance abuse treatment (alcohol, drugs) if
  appropriate
• immunization (HB, HA, influenza, pneumo)

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National Hepatitis C Prevention Strategy

• Prevent new HCV infections
• Detect persons with HCV infection
• prevention of transmission to others medical
  management for chronic liver disease
• Evaluate effectiveness of activities
• Conduct surveillance and research

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Implementation Components National Hepatitis C
Prevention Strategy

• Communication of information on hepatitis C
• State-based prevention programs
• Surveillance
• Epidemiology and laboratory investigations

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Development of State and Local Hepatitis
Prevention Programs
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Viral Hepatitis Prevention at the State/Local
Level A Model
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Development of State and Local Hepatitis C /
Viral Hepatitis Prevention Programs

• Identify stakeholders
• Choose a planning process (consensus meeting,
  consultants, internal)
• Adopt or modify CDCs recommendations
• Identify elements of implementation framework
• Write a plan
• Secure resources to implement plan
• Implement program
• Evaluate and modify program

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Stakeholders in Hepatitis Prevention

• Communicable disease prevention programs
  (surveillance)
• Immunization program
• HIV/AIDS prevention programs (CBOs)
• STD programs
• Substance abuse/mental health programs
• Corrections
• Programs for high-risk youth
• Public and private laboratories
• Public health nursing
• NGOs
• Clinical care primary and specialty care

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Viral Hepatitis Integration Projects (VHIPs)

• Evaluate feasibility of integrating viral
  hepatitis prevention -- immunization, testing,
  counseling, medical referral --
• Into existing programs for
• HIV/AIDS counseling and testing
• STD clinics
• Drug treatment/prevention
• Corrections health
• Develop materials for use by other programs

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CDC State-Based Hepatitis C Prevention Programs
MA
NYC
RI
DC
Demonstration Project
Coordinator
11/01
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Challenges

• Funding and/or referral sources for lab tests,
  vaccines, medical care
• Incorporation of viral hepatitis prevention
  messages into client-centered counseling
• Staff of other programs (HIV/AIDS, STD, drug
  treatment, corrections) may not see viral
  hepatitis prevention as part of their job
• Funding of prevention services flows through
  separate programs (hepatitis, HIV/AIDS, STD,
  immunization,corrections)

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Next Steps

• VHIPs
• Full evaluation of testing and counseling
  component of each project
• Evaluate effectiveness of referral for medical
  evaluation
• New projects for minority populations
• State Programs
• HCV testing and counseling in all HIV/AIDS, STD,
  drug treatment and correction health programs
• Hepatitis B vaccine for all HIV/AIDS, STD, drug
  treatment and corrections health programs

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FundingHepatitis C Prevention Activities

• FY 98 2.0 million
• FY 99 6 million
• FY 2000 13 million
• FY 2001 17 million
• FY 2002 21 million
• FY 2003 Presidents Budget ??